Acute mental confusion and/or fitting
Theory
Acute mental confusion is common. It occurs in 5–15 per cent of all hospitalised patients.
Risk factors include elderly patients, those in ICU/HDU settings or patients with severe or multiple medical problems.
Delirium can be very subtle and you need to suspect the diagnosis.
Many hospitals will have specific guidelines and protocols for the use of drugs in the management of delirium.
Fitting can be caused by epilepsy or a structural/chemical/infectious injury to the brain and is a very serious sign requiring prompt management.
During a fit a patient has a vulnerable airway and is unable to breathe. Management is supportive and aimed at ceasing the fit.
Immediate intern management
Fitting
- Clear environment from around patient to prevent injury.
- If possible, patient can be placed in left lateral position.
- (Do not force patient into this position if the fit will not allow).
- Suction any vomitus from airway.
- Ask nursing staff to get help of other medical staff/call MET code.
- Give oxygen by mask.
- Obtain IV access with nursing assistance, send off basic blood tests and measure at bedside blood sugar level.
- Administer 50 ml 50% Dextrose IV.
- Continue until patient stops fitting and able to eat.
- Give oral glucose.
- Administer:
- Diazepam 5 mg IV (rectal route can be used if delay in obtaining IV access).
- If fitting continues, administer further dose:
- If fitting continues, administer clonazepam 1 mg IV until fitting stops.
- Load with antiepileptic – phenytoin 300 mg loading dose, followed by further dose 300 mg six hours later.
Delirium
- Nurse patient in moderately lit, quiet environment with close supervision.
- Investigate and treat underlying cause.
- Rationalise medications.
- Haloperidol 0.5 mg IM/IV can be used for agitation in these patients.
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Clinical features
History – delirium
- Consciousness
- Fluctuates throughout the day
- Typically worse in late afternoon/night
- Impaired over hours to dayst
- Disorientation
- Behaviour disturbance
- Inactivity/quiet
- Hyperactivity/agitation
- Perception
- Disturbed with delusional features
- Mood disturbance
- Memory impairment
History – fitting
- Epilepsy
- Head trauma
- Headache, vomiting, fever
Examination
- Glasgow Coma Score (GCS)
- Neurological examination
- Localising signs/enlarging pupil
Observation
- Changing or deterioration in:
- Level of consciousness
- GCS
Investigations
Confusion screen:
- Basic blood tests
- FBE, U&E, LFT, TFT
- ABG, cardiac enzymes, blood sugar
- Cultures
- Imaging
Fitting:
- Basic blood tests
- CT brain
Consider:
- Lumbar puncture
- MRI
Definitive management
Delirium
- Appropriate investigations
- Treatment of the underlying cause
- Observation over several days
- Most deliriums will resolve with time
Fitting
- Specialist referral for further investigation
- May require commencement of antiepileptic medications (for example, phenytoin) or adjustment to current medications
- Assess compliance in long term epileptics
- Check recent medication changes for drug interactions
- Consider MRI/lumbar puncture
- Give advice about driving and operating heavy machinery
Causes of confusion
- Sepsis
- Drugs – opiates, sedatives
- Hypoxia
- Alcohol withdrawal
- Metabolic
- Trauma
- Raised intracranial pressure
- Epilepsy
- Hypoglycaemia
- CVA
- Meningitis
- Hyper/hypothyroidism
- Nutritional
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