Delirium/AMS

-Patient is CAM positive (acute onset/fluctuating course + inattention + one of disorganized thinking or AMS).

-No fever, headache, neck stiffness.

-No significant ETOH use to suggest withdrawal.

-No hyperactive delirium + home benzo use to suggest benzo withdrawal.

-No significant opioid use. (Narcan to reverse. Initial: 0.4 to 2 mg; may need to repeat doses every 2 to 3 minutes. A lower initial dose (0.1 to 0.2 mg) should be considered for patients with opioid dependence to avoid acute withdrawal or if there are concerns regarding concurrent stimulant overdose. After reversal, may need to re-administer dose(s) at a later interval (ie, 20 to 60 minutes) depending on type/duration of opioid. If no response is observed after 10 mg total, consider other causes of respiratory depression.)

-Work-up: AXR, PVR, CHEM 10, VBG, O2 sat, LFTs, TSH, glucose, troponin+ECG, CXR, U/A, UCx. Order UTox if overdose suspected.

-Consider CT Head if delirium persists without known precipitant.

-Consider BCx if (active malignancy, neutropenia, immunocompromise, asplenia, central line, dialysis patient, IVDU, recent surgery, obvious portal of infection) OR (one of temperature > 39.4C, suspected endocarditis, indwelling venous catheter) OR (two of: fever, age>65, chills/rigors, vomiting, SBP<90, WBC>18, Cr>177) OR (has CAP plus: ICU admission, cavitary infiltrates, chronic liver dx, asplenia, pleural effuison, active etoh use).

Conservative Tx:

-Benzodiazepines, opiates, anti-psychotics, and anti-depressants are all common causes of drug-induced delirium, and if they can be stopped, they should be.

-Frequent re-orientation to the time, place, person

-Leave a brief summary of where they are and what they are being treated for in front of them to act as a regular reminder

-Try to ensure familiar faces are nearby to reassure the patient (e.g. family members, photos, healthcare professionals who have cared for the patient regularly)

Pharmacological Tx: Melatonin 6 mg PO QHS +/- trazadone 50-200 mg PO QHS +/- Haldol 0.5 mg PO/IM/SQ (repeat q20min, max 5 mg 24 hours) (c/i in Parkinsonism and DLB) +/- lorazepam 0.5 mg PO.

N.B. if dystonia develops (facial grimacing, upward gaze, upper body spasms), give procyclidine 5-10 mg IM or IV.

N.B. if benzo overdose (rare without co-ingestion), give flumazenil 200 mcg IV over 15 seconds, repeat q2min to max 1 mg.