Confusion

Muath Alismail
Outlines
- Case study

- Sign & Symptoms

- Differential Considerations

- Diagnostic Algorithm

- Management
A 70-year-old man with a chief complaint of confusion is brought to the emergency
department by his family.

Which of the following initial assessments should be included?

A. Blood pressure

B. Pulse oximetry

C. Rapid bedside glucose testing

D. Temperature

E. All of these
Answer:

(E) Confusion may result from shock states, hypoglycemia, and hypoxia.

Evaluation for these conditions is a priority. Confusion is a symptom rather than a

medical condition, and reversible remedial causes should be investigated.
Definition
Confusion is an acute alteration in higher cerebral functions, such as memory, attention,
or awareness. The ability to sustain and focus attention is impaired.

Confusion is a symptom, not a diagnosis.

The absence of a chief complaint of altered mental status should not reassure the
emergency clinician that an acute mental status change is absent.

History from family or caregivers, structured physical examination, and use of a specific
assessment tool may be needed to detect the presence of confusion.
Four groups of disorders encompass most causes of confusion:

(1) primary intracranial disease

(2) systemic diseases secondarily affecting the CNS

(3) exogenous toxins

(4) drug withdrawal states

Evaluation through a focused history, physical examination, and rapid bedside screening
assessment tools. Response to specific therapies (eg, dextrose, naloxone) may identify
critical causes.

Vital signs (e.g. fever in infection, low SpO2 in pneumonia) Level of consciousness (e.g.
GCS) Sources of infection (e.g. suprapubic tenderness in urinary tract infection) Asterixis
(e.g. uraemia/encephalopathy)

Additional evaluation may include laboratory testing and diagnostic imaging, which are
usually confirmatory of one of a number of suspected conditions.
Past medical history (e.g. atherosclerosis, stroke, previous episodes
of confusion, head injury, recent admissions)

Current medications: review for drugs that may cause or contribute

to confusion (e.g. opiates)

Social history (e.g. how are they coping at home, excess alcohol,
illicit drug use)
 Assessment

Patients with normal attention function should be able to

perform digit repetition forward (five or six digits) and
backward (four digits).

Additionally, spelling a commonly used word backward

(“world” is frequently used) or listing the months of the year in
reverse order is an accurate screening test.
Postictal confusion is common in patients with seizures, but if improvement in
consciousness does not occur within 20 to 30 minutes after seizure cessation, which of the
following conditions should be considered?

A. all of these

B. electrolyte abnormalities

C. head injury

D. hypoglycemia

E. nonconvulsive or subtle status epilepticus

Answer: A. For a patient with a generalized convulsive seizure, termination of the seizure
activity should be followed by improvement of mental status within a short period of time.
For the patient with persistently altered consciousness or prolonged confusion, consider
causes of provoked seizures with prolonged altered mental status or persistence of subtle
seizures.
Management

Oral or intravenous glucose therapy is indicated if an abnormally low blood glucose level
is discovered. In adults, 25 g dextrose (50 mL of 50% dextrose) is commonly
administered, and the bedside glucose level is checked again.

Hypoxia and hypocapnia are addressed with noninvasive or invasive strategies tailored to
the patient’s presentation.
Management

If a toxidrome is present, treatment is directed toward the specific toxin or syndrome.

DRUG ANTIDOTE

Opioids Naloxone

Benzodiazepines Flumazenil

tricyclic antidepressants Sodium bicarbonate

Beta Blockers Glucagon

Magnesium sulfate Calcium gluconate

Caffeine ?
Management
Age-appropriate antibiotic treatment for coverage of causes of sepsis tailored to the patient’s
comorbidities may be considered in ill febrile patients while a definitive evaluation is in progress. If
a CNS infection is suspected, age-guided empirical antibiotic

In patients with a prolonged postictal period or who are suspected of being in nonconvulsive status
epilepticus, empirical treatment with lorazepam 1 mg IV, up to a maximum of 10 mg, may be
considered pending consultation and additional testing

antipsychotic medications may be used if necessary to decrease agitation, but any of these might
confound evaluation of the confusional state. No studies allow precise recommendation but in adults
we recommend midazolam, titrated beginning with 1 to 2 mg IV or 5 mg IM.
 Take home message

Confusion is a symptom not a diagnosis, Don’t

rest until you find the cause and manage accordingly
 References

1. Han JH, Schnelle JF, Ely EW: The relationship between a chief complaint of “altered mental status” and

delirium in older emergency department patients. Acad Emerg Med 21:937, 2014.

2. Han JH, et al: Delirium in the emergency department: An independent predictor of death within 6 months.

Ann Emerg Med 56:244, 2010.

3. Young GB: Encephalopathy of infection and systemic inflammation. J Clin Neuro- physiol 30:454–461,

2013.

4. O’Regan NO, et al: Attention! A good bedside test for delirium? J Neurol Neurosurg Psychiatry 85:1122–

1131, 2014.
Thank you