Management of Acute Confusional State in Emergency Setting

Initial Assessment and Stabilization

• The American Heart Association recommends immediately assessing and securing the airway, breathing, and circulation (ABCs) as the first priority in any patient with acute confusional state, with a focus on stabilization of vital functions 1, 2
• Checking blood glucose level promptly is crucial to rule out hypoglycemia as a reversible cause of acute confusional state, as recommended by the European Society of Intensive Care Medicine 3
• Monitoring vital signs, including oxygen saturation, is essential because hypoxemia can contribute to or worsen confusion, according to the American Stroke Association 2

Rapid Diagnostic Evaluation

• Determining the time of onset and progression of confusion (last known well time) is vital to establish a timeline, as suggested by the American Heart Association 1
• Performing a targeted neurological examination to identify focal deficits that may suggest stroke or other structural lesions is recommended by the American Stroke Association 2
• Obtaining a comprehensive medication history, with special attention to recently added medications, opioids, sedatives, and anticholinergics, is crucial, as advised by the European League Against Rheumatism 4

Laboratory and Diagnostic Testing

• Ordering a toxicology screen is recommended if drug intoxication is suspected, as suggested by the European League Against Rheumatism 4
• Considering neuroimaging (CT or MRI) when focal neurological signs are present, history of head trauma, or fever without clear source is advised by the European League Against Rheumatism 4 and the European Society of Intensive Care Medicine 3
• Performing lumbar puncture to exclude CNS infection when fever is present without clear source, meningeal signs are present, or immunocompromised status is recommended by the European League Against Rheumatism 4 and the European Society of Intensive Care Medicine 3

Treatment Approach

• Encouraging early mobilization when appropriate is recommended, as suggested by the American College of Surgeons 5
• Minimizing sensory deprivation or overload (appropriate lighting, reduce excessive noise) is advised by the American Academy of Pediatrics 6
• Reserving pharmacological interventions for patients with severe agitation that poses safety risks or prevents essential medical care is recommended by the American Academy of Pediatrics 6
• Using low-dose antipsychotics for severe agitation (haloperidol or atypical antipsychotics) is suggested by the European League Against Rheumatism 4
• Avoiding benzodiazepines as first-line agents except in alcohol/sedative withdrawal is recommended by the American Academy of Pediatrics 6

Special Considerations

• Considering a short and limited trial of hydration to rule out dehydration as a precipitating cause in dying patients with acute confusional state is advised by the European Society for Clinical Nutrition and Metabolism 7, 8
• Using anti-epileptic drug therapy for patients with seizure-related confusion if there are high-risk features for recurrence is recommended by the European League Against Rheumatism 4
• Combining glucocorticoids with immunosuppressive agents for systemic lupus erythematosus with acute confusional state is often effective, as suggested by the European League Against Rheumatism 4

Common Pitfalls to Avoid

• Overlooking medication side effects as potential causes of confusion is a common pitfall, as warned by the European League Against Rheumatism 4
• Using physical restraints as first-line management can worsen agitation and confusion, according to the American Academy of Pediatrics 6
• Administering sedatives without addressing the underlying cause is not recommended by the American Academy of Pediatrics 6

Management of Acute Confusional State

Initial Assessment and Stabilization

• Provide supplemental oxygen to hypoxic patients but not to nonhypoxic patients 9
• Identify and treat fever, as elevated temperature can worsen outcomes 9

Rapid Diagnostic Evaluation

• Screen for common stroke mimics and conditions that present with confusion (see table below) 10

Common Conditions Mimicking or Causing Acute Confusion

• Hypoglycemia: Check in patients with diabetes, decreased consciousness 10
• Hypertensive encephalopathy: Look for headache, significant hypertension, cortical blindness 10

Treatment Approach

• Ensure proper orientation (clocks, calendars, familiar objects) 11
• Encourage family presence when possible 11
• Do not administer haloperidol or risperidone for mild-to-moderate delirium as they have no demonstrable benefit and may worsen symptoms 11
• Consider olanzapine, quetiapine, or aripiprazole for symptomatic management of delirium when necessary 11
• Avoid benzodiazepines as first-line agents except in alcohol/sedative withdrawal 11

Monitoring and Follow-up

• Implement systematic delirium screening at least once per nursing shift using validated tools such as the Confusion Assessment Method (CAM) 12
• Consider dexmedetomidine in surgical patients as it may reduce delirium incidence 12

Acute Confusional State Diagnosis and Management

Essential History and Physical Examination

• The American Academy of Neurology recommends obtaining collateral history from a knowledgeable informant to determine baseline cognitive function and characterize acute changes, as this is foundational to distinguishing delirium from dementia 13
• Assess for symptoms of giant cell arteritis in patients over 50, including headache, scalp tenderness, jaw claudication, and temporal tenderness, as recommended by the American Academy of Ophthalmology 14
• Screen for infection sources, including urinary tract, respiratory, and CNS infections, as suggested by the European League Against Rheumatism 15

Mandatory Laboratory Testing

• Complete blood count with differential is recommended by the European League Against Rheumatism to evaluate for infection and hematologic abnormalities 15
• Comprehensive metabolic panel, including electrolytes, renal function, liver function, and calcium, is suggested by the European League Against Rheumatism 15
• Thyroid function tests are recommended by the European League Against Rheumatism to exclude thyroid disorders 15
• Urinalysis and urine culture are suggested by the European League Against Rheumatism given the high frequency of urinary tract infections as precipitants 15

Selective Advanced Testing

• Perform lumbar puncture when fever is present without clear source, meningeal signs are present, or patient is immunocompromised, as recommended by the European League Against Rheumatism to exclude CNS infection 15
• Order CT head or MRI when focal neurological signs are present, as suggested by the American College of Radiology 16
• The yield of neuroimaging in undifferentiated acute confusional state is only 11%, so selective use based on clinical indicators is appropriate, according to the American College of Radiology 16

Additional Testing in Specific Contexts

• Erythrocyte sedimentation rate and C-reactive protein emergently in patients over 50 with symptoms suggesting giant cell arteritis, as recommended by the American Academy of Ophthalmology 14
• Evaluation for antiphospholipid antibodies and hypercoagulable states in younger patients or when no clear etiology is identified, as suggested by the American Academy of Ophthalmology 14

Assessment and Management of Delirium in ICU Settings

Delirium Screening and Assessment

• The Society of Critical Care Medicine recommends using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC) to screen for delirium in ICU patients, as these tools demonstrate good psychometric properties and are designed for both ventilated and non-ventilated patients 17
• ICU patients at moderate to high risk for delirium should be routinely monitored using validated tools such as the CAM-ICU or ICDSC, with systematic delirium screening at least once per nursing shift 17

Pharmacological Management

• No cited facts are available for pharmacological management in this article, except that the CAM-ICU is recommended for ICU patients 17

Evidence‑Based Evaluation and Management of Acute Confusion in the Emergency Department

Medication Review

• Review all current medications, giving particular attention to anticholinergic agents, benzodiazepines, opioids, sedatives, and any drugs that have been started recently, as these are common reversible contributors to acute confusion. 18

History Taking

• Obtain a focused history that includes recent falls, head trauma, fever, infectious symptoms, alcohol use, and illicit drug use to help identify precipitating factors for altered mental status. 18

Diagnostic Testing

Electrocardiography

• Perform a 12‑lead electrocardiogram on every patient presenting with confusion or somnolence to detect underlying arrhythmias or myocardial ischemia that may explain the presentation. 18

Neuroimaging (Non‑contrast Head CT)

• Order an emergent non‑contrast head CT when any of the following are present: focal neurological deficits, a history of head trauma, fever without an identified source, a new‑onset seizure, or current anticoagulation therapy. These clinical indicators increase the likelihood of a detectable intracranial abnormality. 18

Delirium Screening

Confusion Assessment Method (CAM)

• Apply the Confusion Assessment Method (CAM) in the emergency department to formally diagnose delirium. 18

Two‑Step Screening Process

• Use a two‑step approach: first, a highly sensitive delirium triage screen; second, the Brief CAM to achieve high specificity for delirium detection. 18

Ongoing Reassessment

• Re‑evaluate patients regularly because delirium can fluctuate over short periods, and changes in mental status may signal evolving underlying pathology. 18

Management of Agitation

Non‑pharmacologic Measures

• Avoid the use of physical restraints, as they are associated with worsening agitation and potential harm. 18

Pharmacologic Considerations

• Do not administer benzodiazepines for agitation unless there is a clear indication of alcohol or sedative‑withdrawal syndrome, because they can exacerbate delirium in other contexts. 18

Medication Side‑Effect Vigilance

• Systematically consider medication side effects—especially from anticholinergic drugs and benzodiazepines—as reversible causes of confusion, and discontinue or adjust these agents when appropriate. 18