Define delirium and describe your management approach to this problem in the ICU.
The acute onset of a disturbance of consciousness with inattention, changes in cognition and/orperception, that fluctuates over time, occurs as a consequence of a general medical condition and isnot better accounted for by a pre-existing, established or evolving dementia.
Directed by history, physical examination and differential diagnosis but include/consider;
FBC, EUC, Glucose, LFT, ABG, CXR, ECG, Urinalysis + Dipstick, Septic screen, Urinary Drug Screen.
CT Brain, LP, TTE.
Delirium is a favourite of the examiners. It is discussed in greater depth elsewhere ("Delirium in the ICU")
In order to simplify revision, I reproduce the salient points here:
A systematic approach to this question would resemble the following:
Urgently exclude and manage any lifethreatening aetiologies of delirium:
A) - Look for airway compromise due to decreased level of consciousness
B) - Assess for hypoxia and hypercapnea
C) - Assess for hypotension (thus cortial hypoperfusion) or hypertension (thus, hypertensive encephalopathy)
D) - Exclude hypoglycaemia and intoxication or poisoning; investigate for focal intracranial causes of delirium, such as intracranial haemorrhage or space-occupying lesion. Think about non-convulsive status epilepticus as the cause of delirium. Also consider withdrawal from alcohol and other drugs.
E) - Evaluate electrolytess, looking for hyponatremia
F) - Assess renal function, looking for uremia and dehydration
G) - Assess hepatic function, suspecting hepatic encephalopathy. Don't forget Wernicke's.
H) - Assess bone marrow function - cytopenia may be a clue to a space-occupying metastatic lesion, whereas blood film findings such as macrocytosis may suggest a chronic nutritional deficiency associated with alcoholism or IV drug abuse.
I) - Assess temperature, inflammatory markers and features of sepsis, ranging from UTI to septic shock (thinking about septic encephalopathy). Consider neurosyphilis and think about meningitis or encephalitis.
Investigation of delirium:
Stemming from the abovementioned differentials,
Management of delirium
Oh's Intensive Care manual: Chapter 49 (pp. 549) Disorders of consciousness by Balasubramanian Venkatesh
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