Delirium

Delirium is defined as acute Confusion, with some degree of Agitation.  It’s always a medical (or psychiatric) emergency.  There are countless causes, which must be diagnosed by lab tests & images (x-rays, etc.) in an E.R. 

For example, patients with acute psychotic breakdown, drug overdose on stimulants (cocaine, speed) or hallucinogens (LSD, PCP), and severe lack of oxygen (e.g. from asthma) can all look and act the same. Years ago, before Emergency Medicine became its own specialty, there were cases of asthmatics dying in the “quiet room” (may still occur in small ER’s where generalist clinicians are in charge).

One way to remember all the possible causes to seek out for Delirium, is by the mnemonic “VOWEL TIPS” (“vowel” = A, E, I, O, U; plus the letters T, I, P, S):

A  –  Alcohol:  intoxication (drunk) or withdrawal

• Withdrawal can cause mild seizures on Days 2-3, or life-threatening Delirium Tremens (“DT’s”) on Days 4-5
• Mnemonic “A” also includes brain damage from alcohol, or from liver Cirrhosis

E  –  Epilepsy  (i.e. Seizures, of any cause) or Encephalopathy (brain derangements)

I   –  Infection:   Sepsis; Brain Infections (Meningitis, etc.)

O  –  Opiates  (i.e. also other drugs / medications)

U  –  Uremia (Kidney Failure) & Other Metabolic States

• mnemonic here sort of cheats, because it includes many possibilities:
  • Liver Failure, Thyroid Crisis, Adrenal failure
  • High / Low blood levels of sodium, potassium, calcium, magnesium, etc….

T  –  Trauma, Tumor:

• Brain masses, bleeding, hydrocephalus (spinal fluid overload)

I   –  Insulin:  i.e. related to Diabetes

• Hypoglycemia from medication
• Diabetic coma (severe Hyperglycemia)
• Diabetic Ketoacidosis

P  –  Psychiatric  (Conversion Reaction)

S  –  Shock, Stroke, Syncope, Suffocation

• Lack of oxygen in the brain, various causes

Diagnostic Work-Up is obviously complex, including obtaining History from friends, family, & witnesses as possible (this is most important); Physical Exam; Tests such as:

• Rapid Fingerstick for glucose level (very low or very high)
• Complete Blood Count (CBC)
• Comprehensive Metabolic Panel (CMP)
• Urinalysis
• Toxicology Screen (urine & blood, for drugs)
• Blood gas analysis (levels of oxygen & acids)
• Chest X-ray
• EKG
• CT scan of brain
• Spinal Tap
• Many more

As you can see, there are lots of life-threatening diseases to sort through.