Delirium in the Emergency Department: ED Diagnosis & Management

[00:00:00]hello everyone welcome back to our channnel today I have come with the topic approach to delirium in emergency department so let's see what is delirium what are its causes and how to evaluate and manage an emergency department so let's start so by definition delirium is an acute fluctuating syndrome of altered attention awareness and cognition precipitated by an underlying condition or events in a vulnerable person also known by terms altered mental status acute confusional State sown en kopy and acute organic brain syndrome it develops over a short period and fluctuates during the day delirium is caused by an underlying medical condition classically considered reversible and is not better explained by another pre-existing evolving or established neurocognitive disorder basically there are two diagnostic challenge in assessing for delirium in emergency department first is the clinician must be able to recognize if the patient has delirium and second second is patient needs to be evaluated for medical condition that has precipitated delirium so let's see the types basically delium has three types that is hyperactive delirium hypoactive delirium and a mixed type hyperactive delirium hyperactive delirium is characterized by agitation increased psychomotor activity and heightened level of arousal though less common than the hypoactive delirium but it but this is the most recognizable type seen in less than 10% hypoactive delium this is the the most common type seen in approximately 90% it is more likely to be missed by the clinician because patient may be somnolent unlikely to draw attention to themselves this has the highest mortality rate as it gets missed mix delirium it has alternating hyperactive and a hyperactive state next coming to the causes of delirium so this is how it is easy to Remember by the pneumonic delirium wherein d stands for drugs and deficiencies drugs that cause delirium I'll be discussing it later delum can occur due to drugs and withdrawal of drugs as well and withdrawal of alcohol as well deficiencies is due to vitamin B12 thyine and nasin deficiency e stands for electrolyte imbalances like hypon neia hyper nutria hypocalcemia epilepsy environmental factors like hypo and hypothermia endocrine causes due to hypo or hypoglycemia hypo or hyper thyroid and adrenal insufficiencies L stands for liver failure and low ox o low oxygen as seen in mi and Pulmonary embolism or due to other reasons I stands for infections wherein it can be due to sepsis menitis entis CNS infection and absis R stands for retention where it can be urine or FAL I stands for intracranial causes like hemorrage CVA tiia tumors and Trauma U stands for urmia m stands for Metals wherein we can think of lead and mercury poisoning delirium is made mainly due to two added reasons one is the predisposing factor and the other is the precipitating factor that has led to the present deliria so coming to the predisposing factors it can be due to comorbidities with the underlying liver disease chronic renal failure ihd diabetes and other such conditions next is due to Chronic alcoholism chronic pain age more than 65 and male gender are the predisposing factors coming to premorbid State like inactivity poor functional status and social isolation geriatric syndromes like dementia depression malnutrition poly Pharmacy pressure ulcers and Falls next coming to precipitating factors can be due to acute insults like dehydration fractures hypoxia infection ismia drug indued poor nutrition shock surgery uncontrolled pain urinary or stool retention environmental factors can be an add-on like sleep deprivation ICU settings coming to drugs that cause delirium these are the highrisk drugs which have high propensity to cause delirium that is anticholinergics antihistaminics muscle relaxins benzoins dopamine agonis and midin drugs that have low risk to cause delirium are few antibiotics like quinolones isoniazid linezolid anti-malarials others are anti-hypertensives anti-convulsants tcas and sedativ next coming to assessment of delirium in emergency department the method used for delirium assessment includes cam which stands for confusion assessment method the components in this includes altered mental status or fluctuating course inattention disorganized thinking and altered level of Consciousness in emergency room we have a two-step approach for delirium assessment wherein using a highly sensitive screening tool for delirium that is delirium Triad screen can be performed rapidly to rule out delirium which just takes 10 to 20 seconds this is a delirium trial screen which includes assessment of altered level of Consciousness using Ras if the RAS code is anything abnormal then DTS is positive that is delirium Triad screen and if the RAS is normal then the patient is supposed to be assist for in attention wherein we can assess by asking the patient to spell the word lunch backward if the patient makes one error then DTS is positive further we have to confirm delirium by using bcam that is brief confusion assessment method patient doesn't make any error then the patient's DTS is negative and the patient doesn't have delirium next coming to bcam that is brief confusion assessment method that is used in emergency room which takes around 2 minutes to perform this test is highly specific so the first thing is the altered mental status if the patient has a altered mental status then further patient must assess for inattention if the patient doesn't have a altered mental status then vcam is negative further coming to Inner tension wherein we can ask the patient to name the months backward from December to July if the patient makes no error or just one error then bcam is negative if the patient makes more than one error then patient must be assessed for altered level of Consciousness by using Ras and if the RAS is abnormal then the patients vcam is positive and the patient has delirium if the RAS Cod is normal then patient must be assessed for disorganized thinking wherein we have to ask few of the questions to patients like will a stone float on water are there fish in the sea does one pound weigh more than 2 lbs can you use a hammer to pound a nail hold up two fingers and ask the patient to demonstrate the same thing and if the patient makes no error in this then bcam is negative if the patient makes any error in this then bcam is positive and delium is present next coming to evaluation by in starting with the history taking it is critical to assertain the patient's cognitive Baseline if the patient had a normal cognition the recent sequence of events any history of similar problems or prior epod of deliria any added new medications or withdrawal of any medication underlying comorbidity if the patient had trauma if the patient has any history of alcohol use or substance abuse next coming to examination where in complete General physical examination including Vital Signs has to be assessed complete neurological examination to look for any focal deficit or any positive finding to look for FY of infection and or any drug patch over the body next coming to to further laboratory evaluation where in first and the most important one is to perform a blood glucose test to rule out hypo or hyper glycemia immediately next is serum electrolytes must be evaluated to look for electrolyte imbalances blood Uria nitrogen cread must be checked to rule out uremic en kopy and trans Amis liver function test has to be assessed completely to look for hepatic en copath a urine analysis must be done to check for folky of infection leading to sepsis ABG must be performed to rule out hypercarbia and hypoxia drug levels that is serum drug concentration of psychoactive medications like lithium anti-convulsant theophil dexin and aspirin must be checked TSH must be performed to rule out hypo and hyperthyroidism lactates to rule out sepsis blood culture must be performed in case of sepsis lumbar puncher must be considered in case if there is no other folai found ECG must be performed to rule out mi which can precipitate delirium just xray must be performed if the patient is tepic or has any positive test findings so these are the lab investigations which must be considered apart from this CT and MRI must be considered if the patient has any focal neurological deficit next coming to the Adept tool which is a reference tool for the Emergency Physician while managing and evaluating for delirium which includes a stands for assist D for diagnose e for evaluate P for prevent and T for treat coming to assessment perform a thorough evaluation to determine the underlying cause as I told previously history medication review and a collateral information are crucial perform a thorough physical examination for assessment of cause of delirium diagnosis we have to screen for delirium in any agitated or confused older patient screen for underlying M major neurocognitive disorders such as dementia e stands for evaluate perform a thorough Focus medical workup for agitation and confusion as I told previously coming to prevention individual patient measures must be taken to prevent or manage delirium wherein we have to take care of pain hypoxia address nausea vomiting constipation which can lead to delirium and we have to avoid medication that can precipitate delirium coming to hospital and system based measures to prevent and manage delirium we have to provide a large font clog or other visual cues about the date and location can help self orientation we can limit unnecessary disruptions if possible like un necessary monitors or BP cuff if not required can be avoided these factors can precipitate delirium next coming to treatment which we'll be discussing now so the initial Management in emergency department mainly we aim for stabilizing Airway breathing circulation along with sepine stabilization indicated IV AIS must be placed cardiac monitoring must be done we have to look for reversible causes that can be addressed that is pain hypoxia infection electrolyte imbalances poor nutrition constipation dehydration and lack of sleep these factors must be addressed initially coming to non-pharmacological interventions such as verbal deescalation distraction and reassurance can be used with assistance from family members and staff successful deescalation helps the patient regain control without need for further treatment physical restraints should be avoided because they can lead to injury and if non-pharmacological interventions fail then patient must be treated with chemical restance in that case using a chemical restant our goal is to basically sedate and calm the patient and side by treat the patients underlying cause the agent of choice depends on mitigating side effects and the patients underlying comorbidity coming to the drugs that can be used as a chemical restraint generally a patient with a hyperactive delirium needs a pharmacological treatment antic psychotics are the first line treatment in that case wherein using drugs like predone anpin and haloperidol can be used in the given doses here while using an anticho ECG must be monitored as anti-yo discs can cause QTC prolongation the most preferred medication is haloperidol which can be used in a dose of 1 to 2 milligram preferred preferably given intramuscular haloperidol has a higher risk of extra peramal symptoms than the atypical antic psychotic while using ziprasidone and olanzapine caution must be taken in case of heart failure or card CC disease or in case of intoxicated patients or volume depleted patient benzoins must be avoided as they cause prolonged sedation paradoxic agitation or worsening of delirium in case of alcohol withdrawal benzoins can be considered along with thamin benzoin must not be stopped abruptly few data suggest the use of combination of an Antico and a benzoin improves the clinical Effectiveness that is shorter duration of delirium less extra Pam side effect next is melatonin melatonin has also been implicated in etiopathogenesis of delirium hence remelon was considered for the treatment of delirium coming to selective Alpha 2 receptor agonis that is Dex medoin which also has been found to be beneficial in treatment of delirium in ICU next coming to ECT use of ECT is recommended only in cases where in Delirium is associated with neuroleptic malignance syndrome or to patients who have not responded to the pharmacological agents so these are the drugs used in treatment of delirium coming to disposition all patient with delirium requires admission and close monitoring from emergency department discharge is indicated only if the patient symptoms are resolved in Ed or has a mild symptom with a Clos monitoring with the family members at home so hope this was useful thank you