Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

Rosen & Barkin's 5-Minute Emergency Medicine Consult (194 page)

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ICD9

ICD10

T82.518A Breakdown (mechanical) of other cardiac and vascular devices and implants, initial encounter
Z45.02 Encounter for adjustment and management of automatic implantable cardiac defibrillator
Z95.810 Presence of automatic (implantable) cardiac defibrillator

DELIRIUM
Lori A. Stolz
•
Arthur B. Sanders
BASICS
DESCRIPTION

Delirium is a clinical syndrome characterized by acute changes in awareness, cognition, and perception with a waxing and waning course.
Delirium is a syndrome secondary to an underlying medical condition.
Pathophysiology unknown:
- Diffuse cerebral dysfunction
- Derangements of cerebral acetylcholine
- CNS dopamine, γ-aminobutyric acid, and serotonin may be involved.
Frequently missed by emergency medicine physicians due to atypical chief complaints.
Associated with increased mortality for inpatients and increased length of stay.

ETIOLOGY

Neurologic:
- Meningitis or encephalitis
- Seizure
- Wernicke encephalopathy
- Hypoxia and hypoperfusion of the brain
- Intracranial bleed or mass
Pulmonary:
- Pneumonia
- Other pulmonary etiology of hypoxia
Cardiovascular:
- Hypertensive crisis
- Acute coronary syndromes
- Arrhythmia
GI:
- Hepatic encephalopathy
- Dehydration
Renal:
- UTI
- Acute renal failure
Endocrine:
- Hypoglycemia
- Hyperglycemia
- Hypothyroid
Rheumatologic:
- Collagen vascular disorder
Toxicologic:
- Environmental toxins
- Medications
- Withdrawal from barbiturates or alcohol
Other:
- Electrolyte abnormalities
- Vitamin deficiencies
- Hypothermia
- Hyperthermia
- Trauma

Geriatric Considerations

Common presentation in older ED patients
Up to 10% of older ED patients may have delirium.
Many patients will present with subtle symptoms and vague chief complaints:
- Fall, dizzy, or not feeling well
Waxing and waning symptoms
Cause may be life-threatening condition.

DIAGNOSIS
SIGNS AND SYMPTOMS

Disturbed consciousness:
- Hyperalert:
  - Combative
  - Agitation
- Hypoactive:
  - Lethargic
  - Stupor
  - Coma
- Can have mixed hyperalert and hypoactive state with rapid oscillations
Cognitive changes:
- Disorientation
- Impaired memory
- Disorganized thinking and speech
- Misperceptions, illusions, delusions, and hallucinations
Reduced awareness of environment
Inattention:
- Difficulties in focusing, shifting, and maintaining attention
- Restlessness
- Distractibility
- Lability

History

History from caregivers is essential.
Time course:
- Hours to days
- Fluctuating course
Medications:
- Prescribed, over-the-counter and illicit drugs
- Dosing
- Recently added medications
- Recently discontinued medications
Associated signs, symptoms, pre-existing conditions that would indicate underlying etiology

Physical-Exam

Vital signs
Complete neurologic exam:
- Careful attention to changes in mental status
- Orientation
- Focal deficits
- Hallucinations
Psychiatric exam
Cardiovascular, pulmonary, GI systems.
Use physical exam to determine possible underlying medical illness and to focus further workup, especially sources of infection and sepsis.
Several screening tools are available to evaluate for delirium:
- Confusion assessment method consists of 4 key features:
  - 1: Acute onset or fluctuating course
  - 2: Inattention
  - 3: Disorganized thinking
  - 4: Altered level of consciousness
  - Diagnosis is made when features 1 and 2 are present with either 3 or 4
- Mini-mental state exam:
  - Can be administered serially and will fluctuate; formal cognitive assessment may be difficult to accomplish due to patient cooperation.

ESSENTIAL WORKUP

DIAGNOSIS TESTS & NTERPRETATION
Lab

Initial testing:
- Electrolytes, calcium
- Renal function
- Hepatic function
- Glucose
- CBC
- Urinalysis with culture and sensitivity
- Toxicology screens
Further studies based on signs and symptoms:
- Arterial blood gas
- Thyroid-stimulating hormone
- Cardiac enzymes

Imaging

Diagnostic Procedures/Surgery

DIFFERENTIAL DIAGNOSIS

Other disease processes that should be distinguished from delirium include:
- Psychiatric illness:
  - Symptoms do not have fluctuating course that is typical of delirium.
  - Usually there are no changes in level of consciousness.
  - Delirium is classically associated with visual hallucinations and psychiatric illness with auditory hallucinations.
- Dementia:
  - Delirium has rapid onset, while dementia has a slowly progressive, insidious course without fluctuation of symptoms.
  - Dementia is not associated with acute changes in consciousness.
Once identified as delirium, the differential for the underlying cause is quite extensive.

TREATMENT
PRE HOSPITAL

IV access:
- Pulse oximetry to monitor respiratory status:
  - Glucose measurement
  - ECG monitoring
Naloxone if associated respiratory insufficiency
Monitor patient:
- Advanced life support (ALS) transport with all medications
Look for signs of an underlying cause:
- Medications
- Medical alert bracelets
Document basic neurologic exam:
- Glasgow coma scale score
- Pupils
- Extremity movements

ED TREATMENT/PROCEDURES

When delirium is identified, seek the underlying cause intensely.
Treatment should be targeted at underlying medical condition.
IV line access
Oxygen if indicated by hypoxia
Cardiac, pulse oximetry, and BP monitoring
Thiamine should be administered to alcoholic and malnourished patients.
In patients who are significantly agitated, chemical treatment of agitation may help facilitate ED workup.

MEDICATION

Treatment of delirium should be aimed at underlying condition.
Benzodiazepines should be 1st line for patients with alcohol or benzodiazepine withdrawal.
Benzodiazepines should be avoided in patients with all other causes of delirium, if possible.

First Line

Assess the patient for prolonged QT syndrome before administering antipsychotic agents. Haloperidol: 5–10 mg IV or IM:
- Lower doses (0.5–2 mg) are appropriate for elderly patients.
Recent studies show that atypical antipsychotics may be equally effective to typical antipsychotics.
Thiamine: 100 mg IV, IM, or PO

Second Line