Confusion Flashcards
What are the four DSM IV criteria for delerium?
Disturbance of consciousness - hyperactive or hypoactive
Worsening confusion
Acute onset with fluctuating state
Due to a medical condition, intoxication or withdrawl
What bloods are included in the confusion screen?
FBC and CRP/ESR to look for signs of infection Glucose LFT TFT B12 and folate Calcium, magnesium and phosphate Syphilis serology VBG
What further investigations other than bloods should be done for delirium?
Should have urinalysis +MCandS regardless of symptoms in delerius patients Drug levels to look for toxicity CXR as part of infection screen Head imaging EEG Specific cultures e.g. LP CT if indicated
What are the causes of delerium?
Drug intoxication or withdrawal (anticholinergics, anxiolytics, antidepressants, anticonvulsants, opiates, alcohol)
- Electrolyte imbalance (hypo-/hypernatraemia, hypercalcaemia)
- Liver failure, Low oxygen
- Intracranial pathology (intracranial haemorrhage, stroke, space occupying lesion, epilepsy)
- Renal failure, Retention (urinary retention, constipation)
- Infection (chest, UTI, intra-abdominal, or cellulitis)
- Uraemia and fluid imbalance
- Metabolic (endocrine imbalance: hypo-/hyperglycaemia, hypo-/hyperthyroidism, Addisonian crisis)
- Pain, Postoperative, Psychiatric
What is the management of delerium?
Conservative:
-ensure have spectacles and hearing aids
-quiet environment with clock
-Encourage faily to visit
Medical:
-Dose of paracetamol to aid pain they may not be communicating
-Sedation should only be used if patient is at risk to themself and others
-Rapid tranq with haloperidol 0.5mg PO, or 1-2mg IM every 4 hours
-Second line is Lorazepam - for patients with parkinsons or Lewy body dementia 1mg every 2 hours
What are the components of the cage tool?
Considered cutting down drinking?
Angry about people criticising your drinking?
Guilty about drinking?
Eye opener in the morning?
What investigations should be done in patients with alcohol use?
Should have FBC that may show raised MCV
LFTs can show alcoholic liver disease - raised gamma GT, AST and ALP with AST:ALT >2
Clotting screen
U and Es
Fasting glucose as chronic pancreatitis can lead to DM
How are patients managed to reduce thier alcohol consumption?
Brief interventions (low intensity short interventions in primary care) and motivational interviewing to encourage them to change
CBT
Relapse prevention
AA
What pharmacological interventions are available to aid abstinence?
Disulfiram inhibits ALDH - leading up to acetaldehyde causing flushing, headaches and unpleasant symptoms
Acamprostate enhances GABA transmission and reduces cravings
When does alcohol withdrawl occur?
It occurs 6-72 hours after stopping drinking so should be considered in all patients with acute confusion
What are the symptoms of alcohol withdrawl and how are they assessed?
The symptoms are hypotension, tachycardia and delerium tremens
Assessed with CIWA score that looks at intensity of symptoms to assess likelihood of delerium tremens:
-Tremor
-Anxiety
-Hallucinations
-Etc.
What are the stages of alchol withdrawl?
6-24 hours - Insomnia, tremor, headache
24-72 hours - Withdrawl seizures (tonic clonic)
>72 hours - Delerium tremens - hallucinations, disorientation, tachycardia
What are the triad of features in delerium tremens?
Delirium that fluctuates
Hallucinatory experiences
Tremor
What is the management of patients withdrawing from alcohol?
If low risk of seizures can withdraw in outpatient setting with chlordiazepoxie 20-30mg QDS and 100mg thiamine
If having withdrawl seizures then 100mg loading dose chlordiazepoxide along side 10mg diazepam IV
500mg IV pabrinex TDS should be given to prevent Wernicke-Korsakoff’s syndrome
Why should thiamine be given before IV glucose?
Thiamine is required to breakdown glucose in the krebs cycle so if given glucose then it can quickly repleat their remaining thiamine stores
