Acute assessment of new onset confusion (delirium)

A medical consult is recommended where there is no specific protocol for a condition

Always consider sepsis — signs and symptoms can include

High or low temperature
Fast breathing
Fast pulse
Low BP or dizziness
Confusion and/or agitation

Acute confusion (delirium) is a medical emergency — increased mortality and injury — urgent medical consult
Key features — rapid onset, fluctuating altered level of consciousness (drifting or unable to reliably follow commands), impaired communication, disorientation, altered vital signs
There are 3 types of delirium

Hyperactive delirium — agitation
Hypoactive delirium — patient is withdrawn, mute and drowsy
Mixed delirium — periods of hyperactive delirium and hypoactive delirium

Pre-existing dementia or psychosis can mask an acute delirium — careful assessment is required in these patients

Check

Calculate age-appropriate REWS

Adult — AVPU, RR, O₂ sats, pulse, BP, Temp
Child (less than 13 years) — AVPU, respiratory distress, RR, O₂ sats, pulse, central capillary refill time, Temp

Weight, BGL

If REWS score 3 or more — urgent medical consult
If available POC Test — WBC, electrolytes
U/A, pregnancy test
History, especially medications — taking lots, the wrong way or new medicine
Head-to-toe exam

Table 1.9 Some causes of acute confusion (delirium)

Signs and symptoms Delirium AND	Possible cause
Headache, trauma to head, bleeding from ear/scalp	Head injury
Localised neurological symptoms — weakness, altered limb sensation, changes to vision or speech	Intracranial bleed or clot (stroke) — urget medical consult
Low BP, tachycardia (heart rate over 100), fever/low temperature, shortness of breath, cough, low oxygen Frequency and dysuria, urinary incontinence Pain in limbs, redness of skin Headache, stiff neck	Infection Respiratory infection — medical consult Urinary tract infection Skin/soft tissue infection Central nervous system (CNS) infection (eg meningitis) — medical consult
Low blood glucose levels High blood glucose with normal pH Acidosis (low pH on VBG or low HCO3) and elevated ketones with high blood glucose	Hypoglycaemia Hyperosmolar Syndrome — medical consult Diabetic ketoacidosis
Severe dehydration and/or electrolyte abnormality — low (less than 126mmol/L) or high sodium	Medical consult
Chest pain, sweating, anxiety Fast breathing or shortness of breath, crackles, ankle swelling, low oxygen saturation Rapid heart rate/very slow heart rate	Heart attack Heart failure — medical consult Respiratory failure — medical consult
History of alcohol or other drug misuse New prescribed medicine with side effects decreasing alertness	Alcohol withdrawal Mental health and drug problems Adverse drug reaction — medical consult
Symptoms of depression	Depression — can occur with or appear like dementia