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

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

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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ICD9
  • V45.02 Automatic implantable cardiac defibrillator in situ
  • V53.32 Fitting and adjustment of automatic implantable cardiac defibrillator
  • 996.04 Mechanical complication of automatic implantable cardiac defibrillator
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
  • Awareness of delirium as syndrome is key.
  • Workup should be broad to determine underlying organic disease.
  • Ancillary studies as determined by history, physical, and initial 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
  • ECG
  • Head CT scan
  • CXR
  • Other imaging based on history, physical exam, and possible etiologies
Diagnostic Procedures/Surgery
  • As indicated by potential underlying cause
  • Lumbar puncture if indicated
  • EEG if indicated by potential seizure activity
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
  • Alprazolam: 0.25–0.5 mg PO
  • Lorazepam: 0.5–2 mg IV, IM, or PO
FOLLOW-UP

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