Approach to altered mental status

This is the acute alteration in brain function and may include alteration of arousal or awareness, thought content, memory or attention.

Clinical presentation

Depending on the cause but may include:

• Agitated

• Restlessness

• Hemiparesis

• Visual deficit

• Dysphasia

Differential diagnosis

The mnemonic AEIOU TIPS is widely preferred in the emergency department when considering a broader differential.

• A – Alcohol/acidosis

• E – Epilepsy/Electrolytes

• I – Insulin/Inborn Errors of Metabolism

• O – Oxygen/Overdose

• U – Uremia

• T – Trauma

• I – Infection

• P – Psychiatric/Poisoning

• S – Stroke/Subarachnoid Hemorrhage/Shock

Investigations

• POC Glucose

• Rapid Malaria test

• Blood gases

• Serum Electrolytes

• POC ECG

• Bedside ultrasound

• Serum Creatinine and Urea

• Lactate

• Complete Blood Count

• Liver function tests

• Head CT-scan

• Chest Xray

• Toxicology screening (If highly suspiciousness of intoxication)

Non-pharmacological treatment

• If aggressive/restless consider restraining - mechanical or chemical (medications)

• Obtain set of vital signs including random blood glucose

• Perform both primary and secondary assessment and provide necessary interventions

• Give Oxygen if Hypoxic or dyspnoeic

• Connect the patient to the cardiac monitor to obtain vital signs

Pharmacological treatment

A: diazepam (IV): Adult 5–10mg loading dose, maintenance 0.03–0.1mg/kg every 30 minutes to 6 hours; Paediatrics 0.1–0.15mg/kg stat, may repeat after 3–5 minutes

OR

B: haloperidol (IV): Adult 0.5–10mg *** (If concerned about psychiatric disorder); Child: safety and effectiveness not established

OR

B: ketamine (IV) 1–2mg/kg and 2–4mg/kg for IM

OR

D: midazolam (IV): Adults 5mg stat, maintenance 20–100mcg/kg/hr infusion; Paediatrics 0.05–0.1mg/kg stat

Note

Additional pharmacological treatment will depend on the cause of the altered mental status.

Consult/refer to a higher center with a psychiatrist if concerned about psychiatric disorder.