CNS/ HN - Delirium Flashcards
Differential diagnoses of Delirium/ Disturbed/Confusion/Agitated patients
- UTI*
- Hyponatremia encephalopathy
- Hyponatremia d/t Hydrochlorothiazide
- Delirium Tremens
- Delirium after Burns - Ketamine
- Digoxin Toxicity
- Hypoxia d/t Pneumonia
- Viral Encephalitis
- Dementia - Frontal lobe dementia
Probability diagnosis The 4 Ds: •dementia •delirium (look for cause) •depression •drugs: toxicity, withdrawal
Serious disorders not to be missed Cardiovascular: •CVAs •cardiac failure •arrhythmia •acute coronary syndromes
Neoplasia/cancer:
•cerebral
•cancer (e.g. lung)
Infection: •septicaemia •HIV infection •infective endocarditis Hypoglycaemia/diabetic ketoacidosis Bipolar disorder/mania Schizophrenia states Anxiety/panic Subdural/extradural haematoma
Pitfalls (often missed) Alcohol intoxication/withdrawal Illicit drug withdrawal (e.g. amphetamines) Fluid and electrolyte disturbances Faecal impaction (elderly) Urinary retention (elderly) Hypoxia Pain syndromes (elderly)
Rarities: •postictal state •hypocalcaemia •kidney failure •hepatic failure •prion diseases (e.g. Creutzfeldt-Jakob disease)
Masquerades checklist Depression Diabetes (hypo and hyperglycaemia) Drugs: iatrogenic/social illicit (see list) Anaemia Thyroid disorder (hypo and hyper) Spinal dysfunction (severe pain in elderly) UTI
Is the patient trying to tell me something?
Consider anxiety, depression, emotional deprivation or upset, change in environment, serious personal loss.
Delirium - Key History
Key history
The basis of the history is an accurate account from relatives or witnesses about the patient’s behaviour.
When communicating with the patient, speak slowly and simply, face them and maintain eye contact.
Note the past history and recent psychosocial history, including recent bereavement, family upsets and changes in environment.
Drug history is vital. Perform a mini mental status examination.
Delirium - Key PE
Key examination
- Note the patient’s general demeanour, dress and physical characteristics
- Check vital signs
- Assess the patient’s ability to hear, speak, reason, obey commands, stand and walk
- Look for features of alcohol abuse, Parkinson disease and hypothyroidism
- Examine the neurological systems
- Pulse oximetry (if available)
Delirium - Key Investigations
Key investigations
For delirious or demented patients of unknown cause consider: •MCU urine •blood culture •FBE/ESR •blood glucose •U&E, calcium and phosphate •B12 and folate, vitamin D •TFTs •LFTs •HIV test •arterial blood gases •CXR •cerebral CT scan
Delirium - Diagnostic tips
Diagnostic tips
- The cause may be single or multiple.
- Psychiatric causes include panic disorder, mania, major depression and schizophrenia.
- The key feature of dementia is impaired memory.
- The two key features of delirium are disorganised thought and inattention.
- Prescribed drugs that can cause antisocial behaviour: major and minor tranquilisers, anti-Parkinson, cardiogenic, corticosteroids
Delirium - UTI Case flow
History Consent - SPA HOPI - What do you mean confuse or behavioral changes? - duration? 1st time? - MAWS - halllucination - visual, auditory - Delusions - spy, harm, special power - Memory - short term and long term ( keys, names of relatives) DDX - CNS - Eyes and Ears - Endo - RS - CVS - Abd - Metabolic - Drugs - Diet - Meds - Stress - Psychosocial PMH FH Alcohol and stress
PHYSICAL EXAMINATION
• General Appearance - wearing appropriately for weather? Pallor, Jaundice, LAD, Dehydration • VS • BMI • Hands - -resting tremor/ pill rolling tremor (Parkinson or parkinsonism) -dryness, loss of hair (thyroid) ○ Alcohol abuse § Dupuytren's contracture § IV drug marks • Neuro ○ Complete cranial nerve examination especially § Vision - CN 2,3,4,6 § Hearing - CN 8 § Speech - CN 9,12 ○ Tone ○ Power ○ Reflexes ○ Coordination ○ Sensory
• Face - look * mask facies * thyroid eyes - eye movements + nystagmus - glabellar tap • Neck ○ -thyroid mass • CVS/RS • Abd · Visible distention, any insulin injection marks (if with DM) · mass or tenderness · Suprapubic dullness and tenderness - chronic retention · DRE - check for fecal impaction, melena, prostate enlargement • MMSE - if with memory problem • Office test · Urine dipstick - leukocytes, nitrite, blood, protein · BSL · ECG
Condition -
delirium or in another word “acute brain syndrome or acute confusional state”
changes in mental function and occurs more often among older people.
Common
Cause
Clinical feature
Complication
Management
-admitted in a special delirium unit
- MDT (internal medicine specialists, nurse and psychiatrist..
-Delirium screen
Bloods: FBC, ESR, CRP, UCE, LFT, TFT, BSL, Vit D, B12, Folate, Calcium and phosphate, blood culture if fever
ABG/VBG
urine: urine Na, osmolality, urine MCS, drug screen
imaging (CXR, CT brain, ECG)
-review his medications and change it accordingly
- replace his electrolyte accordingly.
-if possible, the presence of family in the hospital will help him to be reoriented.
Delirium - Hyponatremia Encephalopathy - Indapamide
Counselling
- Approach
- SPA
- HOPI - confusion
- Need to ask the patient about the: BSL, Kidney problem, Liver problem, Diarrhea, Taking any drugs, Any problem with brain/chest, Any weather preferences, increase or decrease of the fluid
- Explain result
- Explain hyponatremic encephalopathy caused by indapamide This is a medication which affects the kidney’s diluting capacity and increases sodium excretion
- common
- causes/ risk factors
- clinical features
- complications - if left untreated can cause brain swelling»_space; life threatening
- reassure
Investigation
- Sodium level,
- Urine osmolality,
- serum osmolality,
- RFTs,
- LFTs,
- BSL,
- UEC.
Basic Investigations:
- Hypoxia: pulse oximetry, oxygen saturation, ABG, CXR
- Sepsis: Blood culture, urine MCS, FBE, ESR/CRP, CXR
- Metabolic: ABG, BSL, urea and electrolytes
- ECG: cardiac enzymes and ECG
- Review Medications: diuretics, benzodiazepines, morphine, alcohol
Management
–admitted in a special delirium unit
- MDT (internal medicine specialists, nurse and psychiatrist..
-Delirium screen
Bloods: FBC, ESR, CRP, UCE, LFT, TFT, BSL, Vit D, B12, Folate, Calcium and phosphate, blood culture if fever
ABG/VBG
urine: urine Na, osmolality, urine MCS, drug screen
imaging (CXR, CT brain, ECG)
-review his medications and change it accordingly
- replace his electrolyte accordingly.
-if possible, the presence of family in the hospital will help him to be reoriented.
Differential Diagnosis - Hyponatremia
- Heart Failure
- Liver Failure
- Kidney Failure
- Vomiting
- Diarrhea
- Blood loss
- Burns
- Sweating
- Renal Loses - Nephropathy , ADH
- Drugs - Indapamide, Imipramine
- SIADH, SCLC,
- Infection - Pneumonia
- Hypothyroidism
Delirium - Hyponatremia - Hydrochlorthiazide
- Approach
- SPA
- HOPI - confusion
- Need to ask the patient about the: BSL, Kidney problem, Liver problem, Diarrhea, Taking any drugs, Any problem with brain/chest, Any weather preferences, increase or decrease of the fluid
- Explain result
- Explain hyponatremic encephalopathy caused by indapamide This is a medication which affects the kidney’s diluting capacity and increases sodium excretion
- common
- causes/ risk factors
- clinical features
- complications - if left untreated can cause brain swelling»_space; life threatening
- reassure
Investigation
- Sodium level,
- Urine osmolality,
- serum osmolality,
- RFTs,
- LFTs,
- BSL,
- UEC.
Basic Investigations:
- Hypoxia: pulse oximetry, oxygen saturation, ABG, CXR
- Sepsis: Blood culture, urine MCS, FBE, ESR/CRP, CXR
- Metabolic: ABG, BSL, urea and electrolytes
- ECG: cardiac enzymes and ECG
- Review Medications: diuretics, benzodiazepines, morphine, alcohol
Management
–admitted in a special delirium unit
- MDT (internal medicine specialists, nurse and psychiatrist..
-Delirium screen
Bloods: FBC, ESR, CRP, UCE, LFT, TFT, BSL, Vit D, B12, Folate, Calcium and phosphate, blood culture if fever
ABG/VBG
urine: urine Na, osmolality, urine MCS, drug screen
imaging (CXR, CT brain, ECG)
-review his medications and change it accordingly
- replace his electrolyte accordingly.
-if possible, the presence of family in the hospital will help him to be reoriented.
Delirium - Delirium tremens - Management
Assess situation
- Is my patient hemodynamically stable? I would like to start with DRABC and call for help and restrain patient as per hospital protocol.
- Ensure and assess DANGER (physical restraints); DRABC
- Institute pulse oximetry and put in high-flow oxygen.
- Intravenous access: Insert IV cannula, collect blood samples for routine hematological and biochemical screens, BSL, blood culture if febrile
- PMHx (DM or CVD), drug use (alcohol),
- Case notes and nursing observation: any recent change in VS, fluid balance, recent drug administration, details of recent surgical procedure (complication, Blood loss), sleep pattern and behavior
- Comments in medical and nursing record and any abnormal laboratory investigations
Physical examination
- Establish orientation
- Check vital signs and examine cardiorespiratory systems
- Look for evidence of sepsis (abdomen and wound)
- Look for evidence of VTE (legs, chest)
- Look for any neurological deficits
- Dipstick and BSL
Causes of Confusion
- Hypoxia (very common cause – particularly in elderly) à ABG, CXR, ECG
- Hypotension
- Sepsis
- Metabolic (electrolytes, blood sugar estimation, arterial pH)
- Cardiac disease (ECG)
- CVA (neurologic examination)
- Pain
- Opiate overdose or effect of other drugs
- Drug withdrawal (alcohol, benzodiazepines, narcotics)
- Exacerbation of pre-existing medical conditions (dementia, hypothyroidism)
Counsel
- Reassure: The situation is under control
- The investigations may yield a cause for confusion
- Alcohol withdrawal is a common cause of postoperative confusion and should be easily controlled and problem self-limiting
- Regular reviews with monitoring of VS, I&O and any changes in behavior
Delirium - Digoxin Toxicity Management
- Toxicity: o Yellow vision (xanthopsia) o Irregular pulse o N/V o Anorexia o Confusion - Treatment: o Stop digoxin o Check potassium o Treat arrhythmia o Digibind IV o Do no combine with verapamil! Management - Admit! - Supportive correct fluid loss - Correct hyperkalemia (insulin, HCO3, correct acidosis) - Management of Arrhythmias: atropine to counteract digoxin - Digoxin FAB fragments: LMW antibodies which combine with digoxin and are then excreted in the urine (40mg vials, each binds about 0.6mg of digoxin)
Delirium - Hypoxia - Management
- admitted in a special delirium unit where he will be looked after by MDT (internal medicine specialists, nurse and psychiatrist..
-Delirium screen
we need to rule out other causes by doing further Ix like
Bloods: FBC, ESR, CRP, UCE, LFT, TFT, BSL, Vit D, B12, Folate, Calcium and phosphate, blood culture if fever
ABG/VBG
urine: urine Na, osmolality, urine MCS, drug screen
imaging (CXR, CT brain, ECG)
-they will review his medications and change it accordingly
-they will repeat his blood test and replace his electrolyte accordingly.
-if possible, the presence of family in the hospital will help him to be reoriented.
-we might give her safe dosage of sedative to calm her down
Delirium - Viral Encephalitis - Management
- From history and examination, most likely he has encephalitis. It is the infection of the brain substance and the covering (meninges) most likely due to a virus. It is a serious condition and needs immediate management. Therefore, we will keep him in the hospital and arrange urgent neurological consultation. In the meantime, I will be giving him oxygen, IV fluids, paracetamol for fever, intravenous lorazepam for active seizures. I would also take blood for baseline investigations such as FBE, ESR/CRP, BSL, LFTs, U&E, Blood culture.
- The treatment is mainly supportive and symptomatic, but the specialist will do further assessment and can order further investigations (EEG – changes in temporal lobe and CSF PCR for HSV) before starting treatment.
- The specialist may prescribe IV acyclovir if HSV is suspected which is one of the main causes of this condition.
- Will he fully recover? It is a serious condition but usually the outcome is good. Don’t worry he is in safe and experienced hands.
- Implications: condition will get worsen, recurrent seizure, fall, head trauma
Differential Diagnosis - Viral Encephalitis
Differential diagnosis - Meningitis - Delirium - Electrolyte Imbalance (Hypo/Hyperglycemia) - Brain abscess - SOL - Substance abuse Head injury
Dementia - Frontal Lobe Dementia
- HOPI - Behavioral changes
- when? 1st time?
- describe?
- Memory problem
- short term vs long term
- Ddx
- CNS
- Eyes and Ears
- Endo
- RS
- CVS
- Abd
- Metabolic
- Diet
- Drugs
- Meds
- Alcohol and Stress
PMH
FH - FH of mental problems
- Psychosocial Hx
- MAWS
- Hallucination
- Delusions
- Suicidal
- Insight
- Heads
Management
- I need to perform MMSE to confirm short term memory loss.
- do frontal lobe cognition tests
- do blood tests (FBE, BSL, UCE, LFT, TFT, vitamin B12) + urine MCS+ ECG
- vision and hearing tests
- refer to psychiatrist for full neuropsychological assessment.
- treatment by mental health team
To carer:
- attend to his hygiene
- he need adequate nutrition
- regular home visit from relative or friends
- not to continue driving as he can put himself and others at risk.
- support group (Dementia self-help group)
