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== Definition ==
==Background==


=== Definition ===
* An acute brain dysfunction syndrome of fluctuating levels of consciousness
* Cardinal features:
** altered mental status and ''fluctuating course''
** ''inattention''
** altered ''level of consciousness'' (i.e. RASS not zero) OR ''disorganized thinking''


*An acute brain dysfunction syndrome of fluctuating levels of consciousness
== Differential Diagnosis ==
*Cardinal features:
**altered mental status and ''fluctuating course''
**''inattention''
**altered ''level of consciousness'' (i.e. RASS not zero) OR ''disorganized thinking''


==Differential Diagnosis==
=== Life-threatening causes (WHHHHIMPS) ===


===Life-threatening causes (WHHHHIMPS)===
* Wernicke's or EtOH withdrawal
* Hypoxia/Hypercarbia
* Hypoglycemia
* Hypertensive emergency
* Hyperthermia/Hypothermia
* Intracerebral hemorrhage
* Meningitis/Encephalitis
* Poisoning
* Status epilepticus


*[[Wernicke encephalopathy|Wernicke's]] or [[alcohol withdrawal]]
=== DIMES ===
*[[Hypoxia]]/[[hypercarbia]]
*[[Hypoglycemia]]
*[[Hypertensive crisis|Hypertensive emergency]]
*Hyperthermia/[[hypothermia]]
*Intracerebral hemorrhage
*[[Meningitis]]/[[encephalitis]]
*Poisoning
*[[Status epilepticus]]


===DIMES===
* Drugs
** Iatrogenic
*** Polypharmacy
*** Opioids (too much or too little)
*** Diphenhydramine
*** Benxodiaepines
** Abuse
*** Alcohol
** Poisoning
** Withdrawal
*** Alcohol
*** Benzodiazepines
* Infections
** Septicemia
** Pneumonia
** Urinary tract infection
** Skin infection or ulcer
* Metabolic
** Endocrine: thyroid, parathyroid, pancreas, pituitary, adrenals
** Electrolytes: sodium, calcium, magnesium, potassium
** Hypoglycemia/hyperglycemia
** Hypoxemia/Hypercarbia
** Hypoosmolar/Hyperosmolar
** Inborn errors of metabolism: porphyria, Wilson's disease
** Nutrition: Wernicke's, B12 deficiency, niacin deficiency
* Environmental
** Surroundings, room changes
* Structures & organs
** CNS
*** Stroke
*** Brain injury
*** Seizures
** Cardiac: heart failure
** Renal: AKI/CKD
** Gastrointestinal: constipation, volvulus
** Genitourinary: retention


*Drugs
== Management ==
**Iatrogenic
***Polypharmacy
***[[Opioids]] (too much or too little)
***[[Diphenhydramine]]
***[[Benzodiazepines]]
**Abuse: [[Alcohol use disorder|alcohol]]
**Poisoning
**Withdrawal
***[[Alcohol withdrawal|Alcohol]]
***[[Benzodiazepine withdrawal|Benzodiazepine]]
*Infections
**[[Sepsis]]
**[[Pneumonia]]
**[[Urinary tract infection]]
**[[Skin and soft tissue infection]] or ulcer
*Metabolic
**Endocrine: thyroid, parathyroid, pancreas, pituitary, adrenals
**Electrolytes: sodium, calcium, magnesium, potassium
**Hypoglycemia/hyperglycemia
**Hypoxemia/Hypercarbia
**Hypoosmolar/Hyperosmolar
**Inborn errors of metabolism: porphyria, Wilson's disease
**Nutrition: [[Wernicke encephalopathy|Wernicke's]], [[Vitamin B12 deficiency|B12 deficiency]], [[niacin deficiency]]
*Environmental
**Surroundings, room changes
*Structures & organs
**CNS
***[[Stroke]]
***Brain injury
***Seizure
**Cardiac: [[heart failure]]
**Renal: [[AKI]]/[[CKD]]
**Gastrointestinal: [[constipation]], [[volvulus]]
**Genitourinary: [[urinary retention]]


==Management==
Treat underlying causes


* Treat underlying causes
=== Pharmacologic ===


===Pharmacologic===
* Opioid neurotoxicity:
** Switch opioid
** Dose reduction
** Hydration
* Medications: Stop medication
* Dehydration: IV or Hypodermoclesis (fluid given subcutaneously)
* Hypercalcemia: IV bisphosphonate (zoledronate/pamidronate)
* Infection: Antibiotics
* Hepatic encepalopathy: Lactulose
* Brain metastases: Corticosteroids


*Opioid neurotoxicity:
=== Non-pharmacologic ===
**Switch opioid
**Dose reduction
**Hydration
*Medications: Stop medication
*Dehydration: IV or Hypodermoclesis (fluid given subcutaneously)
*Hypercalcemia: IV bisphosphonate (zoledronate/pamidronate)
*Infection: Antibiotics
*Hepatic encepalopathy: Lactulose
*Brain metastases: Corticosteroids


===Non-pharmacologic===
* Reduce stimulation
* Low ambient light
* Low noise
* Correct sensory deficits (glasses, hearing aids)
* Gentle, repeated reassurances (but labour intensive)
* Do not use physical restraints Pharmacologic Mild
* Elderly: Haloperidol 0.5mg PO/SQ/IV/IM q4h prn
* End-of-life: Haloperidol 0.5-1mg po or subcut daily or BID + haloperidol 0.5-1mg po/SC q1h prn Moderate
* Haloperidol 2-2.5mg po/sc bid or tid + haloperidol 2mg po/sc q1h prn
* Or methotrimeprazine 5-12.5mg po/sc bid or tid + prn Severe
* Elderly: haloperidol 1mg, or quetiapine 12.5mg if long QT
* Midazolam 2.5-5mg sc stat once + haloperidol 5mg sc stat
* Or methotrimeprazine 25mg sc stat then po/sc
* Follow with haloperidol 2.5-5mg sc q30min prn (max 10-15mg/day) Subdowning
* Methotrimeprazine qhs Alternatives
* Quetiapine
* Risperidone
* Olanzapine


*Reduce stimulation
== RASS Scale ==
*Low ambient light
*Low noise
*Correct sensory deficits (glasses, hearing aids)
*Gentle, repeated reassurances (but labour intensive)
*Do not use physical restraints Pharmacologic Mild
*Elderly: Haloperidol 0.5mg PO/SQ/IV/IM q4h prn
*End-of-life: Haloperidol 0.5-1mg po or subcut daily or BID + haloperidol 0.5-1mg po/SC q1h prn Moderate
*Haloperidol 2-2.5mg po/sc bid or tid + haloperidol 2mg po/sc q1h prn
*Or methotrimeprazine 5-12.5mg po/sc bid or tid + prn Severe
*Elderly: haloperidol 1mg, or quetiapine 12.5mg if long QT
*Midazolam 2.5-5mg sc stat once + haloperidol 5mg sc stat
*Or methotrimeprazine 25mg sc stat then po/sc
*Follow with haloperidol 2.5-5mg sc q30min prn (max 10-15mg/day) Subdowning
*Methotrimeprazine qhs Alternatives
*Quetiapine
*Risperidone
*Olanzapine

==RASS Scale==


[[Category:Neurology]]
[[Category:Neurology]]

Revision as of 20:22, 22 February 2021

Background

Definition

  • An acute brain dysfunction syndrome of fluctuating levels of consciousness
  • Cardinal features:
    • altered mental status and fluctuating course
    • inattention
    • altered level of consciousness (i.e. RASS not zero) OR disorganized thinking

Differential Diagnosis

Life-threatening causes (WHHHHIMPS)

DIMES

Management

  • Treat underlying causes

Pharmacologic

  • Opioid neurotoxicity:
    • Switch opioid
    • Dose reduction
    • Hydration
  • Medications: Stop medication
  • Dehydration: IV or Hypodermoclesis (fluid given subcutaneously)
  • Hypercalcemia: IV bisphosphonate (zoledronate/pamidronate)
  • Infection: Antibiotics
  • Hepatic encepalopathy: Lactulose
  • Brain metastases: Corticosteroids

Non-pharmacologic

  • Reduce stimulation
  • Low ambient light
  • Low noise
  • Correct sensory deficits (glasses, hearing aids)
  • Gentle, repeated reassurances (but labour intensive)
  • Do not use physical restraints Pharmacologic Mild
  • Elderly: Haloperidol 0.5mg PO/SQ/IV/IM q4h prn
  • End-of-life: Haloperidol 0.5-1mg po or subcut daily or BID + haloperidol 0.5-1mg po/SC q1h prn Moderate
  • Haloperidol 2-2.5mg po/sc bid or tid + haloperidol 2mg po/sc q1h prn
  • Or methotrimeprazine 5-12.5mg po/sc bid or tid + prn Severe
  • Elderly: haloperidol 1mg, or quetiapine 12.5mg if long QT
  • Midazolam 2.5-5mg sc stat once + haloperidol 5mg sc stat
  • Or methotrimeprazine 25mg sc stat then po/sc
  • Follow with haloperidol 2.5-5mg sc q30min prn (max 10-15mg/day) Subdowning
  • Methotrimeprazine qhs Alternatives
  • Quetiapine
  • Risperidone
  • Olanzapine

RASS Scale

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