Altered level of Conciousness

Altered level of Conciousness

Overview

Definition
Delirium: Cognitive impairment typically caused by acute illness or drug toxicity (sometimes life threatening) and is often reversible. Delirium mainly affects attention.
Confusion: disturbed orientation in regard to time, place, or person, sometimes accompanied by disordered
Dementia: Cognitive impairment typically caused by anatomic changes in the brain, has slower onset, and is generally irreversible. Dementia mainly affects memory.

Differential diagnosis of altered level of Consciousness - AEIOUTIPS)

  1. Alcohol
  2. Electrolyte imbalance, Endocrine problems
  3. Insulin (Hypoglycemia)
  4. Opiates or Overdose
  5. Uremia or Underdose
  6. Trauma (Closed Head Injury), Temperature (Hypothermia, hyperthermia), or Toxemia, Brain Tumor
  7. Infections (Sepsis, Meningitis, Encephalitis)
  8. Psychogenic,  Poisoning (Toxin Ingestion)
  9. Space occupying lesions, Stroke (including Intracranial Pressure), Shock, Seizure
Remember Confusion is not specific to delirium; it may be found in other psychiatric disorders, such as dementia or depression.
Difference between Dementia and Delirium
Dementia Delirium
Onset Sub-acute Acute
Conscious level Normal Fluctuates
Hallucinations Late event Common
Agitation/agression Uncommon until late Common
Thought form Poverty of thought late Flight of ideas
Memory Slow decline Poor

Approach

  • History
  • Examination
  • Investigation
    • Blood sugar level
    • FBC
    • EUC
    • Paracetamol level
    • Alcohol level
    • Urinalysis
    • Urine drug screen if available
    • +/- Head CT/MRI

Altered level of consciousness turning agitated and violent

Steps to take

  • Assess
  • Reassurance
  • Verbal de-escalation
    • Empathy
    • I want to help
    • Positive
  • Physical restraint
    • Indications
      • Preventing harm to the patient
      • Preventing harm to other patients
      • Preventing harm to staff
      • Preventing serious disruption or damage to the environment
      • To assist in assessing and management off the patient
    • Mental Health Act Victoria 2014
  • Chemical restraints
    • Indications as above

Management - chemical retraint

  • Benzodiazepam or antipsychotics - Oral
  • Benzodiazepam or antipsychotics - IM/IV
Think If someone is aggressive, person probably would not want to take in any medication orally or have something injected Intravenously.

 Complications of Chemical restraining

  • Benzodiazepams overdose
    • Drowsiness, confusion
    • Dysarthria
    • Ataxia
    • Impaired coordination
    • Coma
    • Respiratory depression
    • Death
  • Antipsychotics overdose
    • Tachycardia
    • Hypotension
    • QT prolongation on ECG
    • Anticholinergic syndrome
      • Hyperthermia
      • Urinary retention
      • Hallucinations
      • Flushing
    • Neuroleptic malignant Syndrome - Atypical antipsyhotics
      • Hyperthermia
      • Autonomic instability
      • Neuromuscular rigidity
      • Altered mental status.

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