When to intubate in GCS?

GCS ≤ 8 requires intubation for airway protection. The patient cannot protect their own airway at this level of consciousness. Motor score is the most prognostically important component.

What is the best initial fluid for sepsis resuscitation?

Lactated Ringer's (LR) is the preferred resuscitation fluid. The SMART trial (2018) showed balanced crystalloids reduced death, new renal failure, and persistent renal dysfunction compared to normal saline.

When to start vasopressors in septic shock?

Start norepinephrine (first-line vasopressor) if MAP remains < 65 mmHg after initial 30 mL/kg crystalloid resuscitation, or earlier if patient is profoundly hypotensive. Do not delay pressors to complete full fluid resuscitation.

Why can serum uric acid be normal during acute gout?

During acute inflammation, IL-6 increases renal urate excretion and redistributes urate from plasma to tissues. Up to 40% of acute gout flares have normal serum uric acid. Joint aspiration with polarized microscopy is needed for definitive diagnosis.

How do you distinguish lupus flare from infection in SLE?

Key clues: CRP is low/normal in flare but elevated in infection. Complement (C3/C4) drops in flare but is normal/elevated in infection. Procalcitonin is elevated in bacterial infection but normal in flare. Anti-dsDNA rises in flare, stable in infection.

What is the difference between DKA and HHS?

DKA features acidosis (pH 600), hyperosmolality (> 320), and minimal ketosis -typically in Type 2 DM. DKA requires insulin drip; HHS requires aggressive fluid resuscitation first.

When to give tPA in acute ischemic stroke?

IV alteplase (tPA) can be given within 4.5 hours of last known well time in eligible patients. CT head must rule out hemorrhage first. For large vessel occlusion, mechanical thrombectomy can be performed up to 24 hours with favorable imaging.

What antibiotics for community-acquired pneumonia?

Inpatient non-ICU: ceftriaxone + azithromycin. ICU: ceftriaxone + azithromycin (add vancomycin if MRSA risk). Outpatient healthy: amoxicillin. Outpatient with comorbidities: augmentin + azithromycin or respiratory fluoroquinolone. Duration: 5 days if clinically stable for 48 hours.

How to interpret iron studies?

Iron deficiency: low ferritin (< 30), high TIBC, low iron, low transferrin saturation (< 20%). Anemia of chronic disease: normal/high ferritin (acute phase reactant), low TIBC, low iron. A ferritin of 50-100 in an inflamed patient may still represent iron deficiency.

What is the correction rate for hyponatremia?

Correct sodium no more than 8 mEq/L in 24 hours to avoid osmotic demyelination syndrome (ODS). For symptomatic severe hyponatremia with seizures, give 3% hypertonic saline 100-150 mL bolus over 10-20 minutes. If overcorrected, use D5W + DDAVP rescue protocol.

When to start antibiotics in meningitis?

Within 30-60 minutes. Do NOT delay antibiotics for LP or CT. Draw blood cultures, start empiric antibiotics (vancomycin + ceftriaxone ± ampicillin if > 50 or immunocompromised), then perform LP when possible. Dexamethasone should be given before or with the first antibiotic dose.

DOACs vs warfarin in antiphospholipid syndrome?

DOACs are contraindicated in APS. The TRAPS trial (2018) showed rivaroxaban was inferior to warfarin with more thrombotic events in triple-positive APS patients. Warfarin with INR target 2-3 is the standard for APS, indefinitely.

How to manage scleroderma renal crisis?

ACE inhibitors (captopril) are life-saving -start immediately and titrate aggressively. Do NOT hold for rising creatinine. Steroids > 15 mg prednisone per day precipitate scleroderma renal crisis. ARBs are NOT a substitute -evidence is only for ACEi.

What are the 4 pillars of heart failure treatment?

Guideline-directed medical therapy (GDMT) for HFrEF: (1) ARNI or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) MRA (spironolactone or eplerenone), (4) SGLT2 inhibitor (dapagliflozin or empagliflozin). All four should be initiated and titrated to target doses.

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CommonNeurology

Altered Mental Status & Delirium

Delirium affects 20–30% of hospitalized patients and up to 80% in ICU. It's a syndrome, not a diagnosis -always find the cause. The hallmark: acute change in attention that fluctuates. Prevention is better than treatment -benzos make it worse.

🔍 Overview

Delirium vs Dementia

Feature	Delirium	Dementia
Onset	Acute (hours–days)	Chronic (months–years)
Course	Fluctuating (waxes and wanes)	Progressive, stable day-to-day
Attention	Impaired (cardinal feature)	Preserved until late stages
Consciousness	Altered (hyperalert or obtunded)	Clear until late stages
Reversibility	Reversible (treat the cause)	Irreversible (but delirium can be superimposed on dementia)

Screening -CAM (Confusion Assessment Method)

Requires feature 1 AND 2 PLUS either 3 OR 4:

1. Acute onset with fluctuating course (was fine yesterday, confused today, better this afternoon, worse tonight)
2. Inattention (can't recite months backward, can't spell WORLD backward, easily distracted) -most important feature
3. Disorganized thinking (incoherent speech, illogical flow of ideas)
4. Altered level of consciousness (anything other than alert -lethargic, stuporous, hyperalert, agitated)

CAM-ICU is the version for intubated/non-verbal patients -uses RASS for consciousness level and a visual attention task (squeeze my hand when you see the letter A).

AMS Workup -"AEIOU TIPS"

Letter	Cause	Workup
A	Alcohol (withdrawal or intoxication), acidosis	BAL, urine tox, ABG, CIWA
E	Electrolytes (Na⁺, Ca²⁺, glucose, Mg), endocrine (thyroid, adrenal)	BMP, Ca, Mg, PO₄, TSH, cortisol, glucose
I	Infection (UTI, pneumonia, meningitis, sepsis)	CBC, UA, CXR, blood cultures, LP if indicated
O	Oxygen (hypoxia, hypercarbia, CO poisoning)	ABG, SpO₂, CO level if suspected
U	Uremia, hepatic encephalopathy	BUN/Cr, ammonia, LFTs
T	Trauma, temperature (hypo/hyperthermia)	Head CT, core temp
I	Iatrogenic (medications -#1 modifiable cause)	Med review: benzos, opioids, anticholinergics, steroids, polypharmacy
P	Psychiatric (diagnosis of exclusion), post-ictal	Rule out organic causes first. EEG if concern for non-convulsive status
S	Stroke, seizure, space-occupying lesion	CT head, MRI, EEG

🚨 Management

Non-Pharmacologic -FIRST

Non-pharmacologic prevention reduces delirium incidence by 30–40%. This is more effective than any drug.

Reorient frequently -clock, calendar, whiteboard with date/nurse/doctor name, familiar objects from home
Sleep hygiene -lights off at night, minimize nighttime vitals/meds/interruptions, cluster care, earplugs, eye mask
Early mobilization -out of bed, PT/OT, minimize restraints (restraints worsen delirium)
Sensory aids -glasses, hearing aids (at bedside, not in a drawer)
Remove lines/catheters ASAP -Foley, central lines, telemetry if not needed
Medication review -stop/minimize anticholinergics (diphenhydramine, hydroxyzine, oxybutynin), benzos, opioids. Use the Beers List.
Treat pain -undertreated pain causes delirium too. Use scheduled acetaminophen, avoid PRN opioids only.
Avoid physical restraints -they worsen agitation and prolong delirium

Pharmacologic -ONLY If Necessary

Drug	Dose	When	Notes
Haloperidol (Haldol)	0.5–2 mg IV/IM/PO q4–6h PRN	Agitated delirium threatening safety (pulling lines, aggression)	No evidence it shortens delirium duration. Use lowest effective dose, shortest duration. Monitor QTc (hold if QTc > 500). Avoid in Parkinson's (worsens motor symptoms).
Quetiapine (Seroquel)	25–50 mg PO at bedtime	Sundowning, nocturnal agitation, ICU delirium	Lower EPS risk than haloperidol. Sedating. Preferred in Parkinson's and Lewy body dementia (less D2 blockade). Start 12.5–25 mg in elderly.
Dexmedetomidine	0.2–1.5 mcg/kg/hr IV	ICU delirium (intubated patients)	MENDS, 2007: dex reduced delirium duration vs midazolam in ICU. SEDCOM, 2009: less delirium (54% vs 76.6%) and shorter extubation time vs midazolam. DahLIA, 2016: dex resolved agitated delirium faster and reduced ventilator time. No respiratory depression. Preferred ICU sedative for delirium.

BRAIN-ICU, 2013: ICU delirium duration is independently associated with worse long-term cognitive outcomes at 3 and 12 months -underscoring the importance of aggressive delirium prevention and treatment.

Benzodiazepines WORSEN delirium in almost all cases. Diphenhydramine (Benadryl) is NOT a sleep aid, it's an anticholinergic that causes and worsens delirium. Remove it from every patient's med list.

Delirium in the Elderly: Medication Nuances

Elderly patients are the highest-risk population for both delirium and for harm from the drugs we use to treat it. Non-pharmacologic first (HELP, reorientation, sleep, mobility, sensory aids, remove tethers, med reconciliation). Drugs are a last resort for severe agitation that threatens patient or staff safety. The points below address the two questions that get pimped most: when are benzos ever acceptable in an elderly delirious patient, and what is the right antipsychotic and dose.

When Benzodiazepines ARE Indicated in Elderly Delirium

General rule: benzos worsen delirium and are contraindicated in the elderly for routine agitation. The exceptions, ordered by frequency on wards:

Exception	Agent / Dose	Why Benzos Are Correct Here
Alcohol withdrawal delirium (DTs) Most common benzo indication in elderly delirium	Lorazepam 1–2 mg IV q1–2h symptom-triggered (CIWA), or diazepam 5–10 mg IV loading. Prefer lorazepam in liver disease.	Benzos replace the GABA tone that alcohol was providing. Underdosing kills (seizures, aspiration). Haloperidol lowers seizure threshold and does NOT treat withdrawal.
Benzodiazepine withdrawal	Restart a long-acting benzo (diazepam or chlordiazepoxide) at equipotent dose, then taper by 10–25% every 1–2 weeks.	Abrupt discontinuation of chronic benzos causes a withdrawal delirium that mirrors DTs. Requires slow taper, not abstinence.
Catatonia (often mistaken for hypoactive delirium) Mutism, staring, waxy flexibility, posturing	Lorazepam 1–2 mg IV/IM challenge (both diagnostic and therapeutic). If response, continue 1–2 mg q4–6h scheduled.	Catatonia responds rapidly to lorazepam. Antipsychotics can worsen or trigger malignant catatonia, so get the diagnosis right first. Always consider catatonia in a quiet, unresponsive elderly patient.
Seizure or non-convulsive status epilepticus (NCSE)	Lorazepam 2–4 mg IV, then load anti-seizure med (levetiracetam, fosphenytoin).	Persistent post-ictal confusion or fluctuating delirium with no clear cause should trigger EEG. Benzos stop the seizure, ASM prevents recurrence.
Neuroleptic malignant syndrome (NMS) or serotonin syndrome	Lorazepam 1–2 mg IV q4–6h as adjunct to supportive care.	Benzos reduce rigidity and agitation. Primary treatment is stopping the offending agent and cooling; benzos buy time and reduce muscle breakdown.

Not an exception: "He was agitated so I gave him Ativan." Routine agitation in an elderly delirious patient is NOT an indication for a benzo. It prolongs delirium, increases fall risk, and worsens aspiration. Use a low-dose antipsychotic instead, and run the mimic sweep first, see the Acute Agitation tab for the bedside playbook.

Antipsychotic Selection in Elderly Delirium

Start with the lowest effective dose, use for the shortest duration, and stop as soon as agitation resolves. Remember MIND-USA, 2018: antipsychotics do not shorten delirium duration or improve mortality, they only manage dangerous agitation.

Agent	Elderly Dose	When to Choose	Cautions
Haloperidol (Haldol) FIRST LINE	0.25–0.5 mg PO/IV/IM q4–6h PRN. Max ~3 mg/24h in frail elderly.	Hyperactive agitation threatening safety (pulling lines, aggression). Non-Parkinsonian patient.	Check QTc before dosing, hold if > 500. EPS, akathisia. Contraindicated in Parkinson's and Lewy body dementia (precipitates motor crisis).
Quetiapine (Seroquel) DLB / PARKINSON'S	12.5–25 mg PO at bedtime, can give 12.5 mg q12h PRN. Start low, titrate slowly.	Parkinson's disease, Lewy body dementia, sundowning, nocturnal agitation. Less D2 blockade so fewer motor side effects.	Sedating (can cause daytime somnolence). Orthostatic hypotension in elderly. Still carries the FDA black box warning.
Risperidone (Risperdal)	0.25–0.5 mg PO BID PRN.	Alternative to haloperidol when oral route available.	EPS at higher doses. Orthostatic hypotension. Not preferred in Parkinson's / DLB.
Olanzapine (Zyprexa)	2.5–5 mg PO or IM q8–12h PRN.	Refractory agitation, when oral route fails and IM needed.	Sedation, weight gain, anticholinergic effects at higher doses, orthostatic hypotension.
Dexmedetomidine ICU ONLY	0.2–1.5 mcg/kg/hr IV infusion.	ICU delirium, especially ventilated patients or when extubation is imminent. MENDS, 2007, SEDCOM, 2009, DahLIA, 2016.	Requires continuous monitoring. Bradycardia, hypotension. Not for floor patients.

FDA black box warning: all antipsychotics (typical and atypical) carry a boxed warning for increased all-cause mortality in elderly patients with dementia-related psychosis, driven mostly by cerebrovascular events and pneumonia. Use the lowest effective dose, shortest duration, document indication and discussion of risks, and stop as soon as acute agitation resolves. Do NOT continue on discharge without a clear plan to taper.

Also avoid in elderly delirium: diphenhydramine (anticholinergic, not a sleep aid), hydroxyzine (anticholinergic), meperidine (active metabolite causes delirium and seizures), metoclopramide (can worsen agitation and cause EPS), cyclobenzaprine, oxybutynin, and promethazine. All are on the Beers List and are among the top offenders for hospital-acquired delirium.

⚠️ Acute Agitation on the Wards

Every agitation call is a workup before it's a prescription. The 5-minute bedside sweep below catches the reversible causes that look like delirium but kill faster if missed. Run it BEFORE writing for haloperidol, every time. Hyperactive delirium IS agitation in ~95% of ward cases, so the workup half of this topic still applies. This tab is the "you walked into the room at 3 AM" execution layer.

Step 1, The 5-Minute Mimic Sweep

These are the agitation mimics that get treated wrong if you sedate first. Order reflects "fastest to kill if missed."

Mimic	How to catch it in 60 sec	Why this is the first move
Hypoxia	SpO₂, RR, accessory muscle use	A hypoxic patient sedated with haldol stops fighting AND stops breathing. SpO₂ before any sedative, no exceptions.
Hypoglycemia	Fingerstick	Looks identical to delirium. Missed → seizure, anoxic injury, death. D50 1 amp IV solves it in 90 seconds.
Alcohol or BZD withdrawal	Tremor, HR, BP, diaphoresis, last-drink history, CIWA score	Haloperidol does NOT treat withdrawal AND lowers seizure threshold. Wrong drug here = grand mal seizure on the floor.
Urinary retention or fecal impaction	Bladder scan, suprapubic exam, rectal	A 1-liter bladder is a top cause of "sudden delirium" in older men. Straight-cath fixes it without a single milligram.
Uncontrolled pain	Grimacing, guarding, surgical site, fracture, ischemic limb. PAINAD scale if non-verbal.	Under-treated pain is the most common reversible trigger of post-op agitation. Antipsychotic without analgesic just snows a hurting patient.
Hypercapnia	COPD/OSA history, recent opioids, somnolence preceding agitation. VBG/ABG if suspected.	CO₂ narcosis presents as agitation BEFORE somnolence. Sedating accelerates the crash to intubation.
Acute intracranial event	Focal exam, recent fall, anticoagulation, asymmetric pupils, new headache	Anticoagulated patient with new agitation = non-contrast head CT before sedation. A sedated stroke patient masks the deficit.
NMS or serotonin syndrome	Rigidity, hyperreflexia (SS) or lead-pipe rigidity (NMS), fever, recent antipsychotic or serotonergic agent	BOTH contraindicate haldol. Stop offender, cool, supportive care; benzodiazepines are correct here, antipsychotics are not. See NMS vs Serotonin Syndrome.

Step 2, Verbal De-Escalation and Non-Pharm

These cost nothing and run in parallel with the mimic sweep. Most ward agitation episodes end here without a milligram of anything.

One staff member talks, others step back. Multiple voices escalate. Get to eye level, hands visible, slow speech. Why: a delirious frontal cortex is overwhelmed by stimulus; reducing inputs is the fastest de-escalation lever.
Reorient briefly, then validate. "Mr. K, you're at the hospital, it's Tuesday morning, your daughter is on her way. I can see you're frustrated." Why: validation before redirection. Telling a delirious patient "calm down" is data they can't process; "I can see you're upset" is.
Glasses on, hearing aids in, dentures in. Why: you cannot de-escalate someone who can't see or hear you. Sensory deprivation manufactures agitation; every encounter without aids generates more confusion.
Lights up, curtains open, TV off, monitor alarms silenced if safe. Why: ambient stimulus drives the hyperactive subtype. Daytime light also re-anchors circadian rhythm, which is a downstream delirium fix.
Untether what you can. Foley out if not needed, telemetry off if not indicated, IV moved to less prominent arm. Why: tethers are the #1 thing patients pull at, AND Foleys cause CAUTI which causes more delirium = vicious loop.
Family at bedside, even at 2 AM. Phone-speaker if family can't come in. Why: a familiar voice often resolves what no drug will. Family also remember the patient's baseline and can tell you what's actually different.
Toileting offer + warm drink + snack. Why: "is there something you need?" fixes a surprising fraction of "agitated" patients. The complaint is often something basic the resident skipped past.
1:1 sitter as soon as available. Why: always preferred over restraints. Restraints INCREASE agitation, injury, pressure ulcers, aspiration risk, and prolong delirium. A sitter de-escalates; a restraint escalates.

Step 3, Pharmacologic Management (Narrow Indications Only)

Indications, document them in the chart: imminent risk of harm to self or staff, OR pulling lines/tubes essential for medical care, OR refusing essential treatment in a patient lacking capacity due to delirium. NOT for hypoactive delirium, not for sundowning alone, not for sleep, not because the patient is "annoying the nurses."

Goal: calm and arousable, NOT asleep. Snowing the patient just delays the diagnosis and prolongs LOS. Antipsychotics manage behavior; they do NOT shorten delirium duration (HOPE-ICU, 2013, MIND-USA, 2018, AID-ICU, 2022).

First-Line: Haloperidol

Dose: 0.25–0.5 mg PO/IV/IM in older adults (≥ 65 or frail). 1–2 mg in younger non-frail adults. May repeat q30 min PRN. If you're past ~3 mg/24h on the wards, stop and reassess, the diagnosis is wrong or the patient needs a higher level of care.
Onset: IV ~5–10 min, IM ~15–30 min, PO ~30–60 min. Pick the route to match how fast you need control AND how cooperative the patient is.
Why first-line: decades of ward use, IV/IM/PO all available, no active metabolites, minimal hypotension, minimal anticholinergic load.
Pre-dose checks: EKG (QTc < 500), K, Mg. Repeat EKG after cumulative dose ≥ 2 mg or any other QT-prolonger on board. Why: haloperidol prolongs QT and torsades is the dose-related lethal complication.
Avoid in: Parkinson's disease, Lewy body dementia, prior NMS, QTc > 500, alcohol or BZD withdrawal as the primary cause.

When Haloperidol Is Contraindicated

Scenario	Drug	Dose	Why this one
Parkinson's disease or Lewy body dementia	Quetiapine (Seroquel)	12.5–25 mg PO; can repeat q12h	Least D2 blockade of the antipsychotics → least extrapyramidal effect. Haldol can precipitate parkinsonian crisis or NMS in these patients.
QTc 470–500 or other QT concern	Olanzapine (Zyprexa)	2.5–5 mg PO/IM (PO disintegrating available)	IM available when refusing PO, less QT effect than haldol at low doses. Anticholinergic at higher doses, so keep it low in elderly.
Need oral, haldol contraindicated for non-Parkinson's reason	Risperidone (Risperdal)	0.25–0.5 mg PO BID PRN	Solid PO option when IV access is fine and you need a lower-EPS-risk-than-haldol agent. Avoid in Parkinson's and DLB.

When First-Line Is Inadequate, Escalation Options

A first dose of haldol 0.5 mg may not produce control in 30 minutes. Two legitimate moves before switching agents: (1) repeat the dose if EKG and tolerance are fine and cumulative is still < 3 mg/24h; (2) re-run the mimic sweep, you may have missed the trigger. If repeat dosing fails OR causes EPS/akathisia, switch agents. The parenteral options below are listed in approximate order of how often they are reached for on the wards.

Drug	Dose	Onset	When to choose / cautions
Droperidol (Inapsine) FAST IV	2.5 mg IV/IM, may repeat q15-30 min. Cap ~10 mg/24h on the wards. (5 mg in younger non-frail adults; 1.25 mg in the very elderly.)	IV 3-10 min IM 15-30 min	Butyrophenone (same class as haldol) with faster IV onset and more sedation per milligram. Carries an FDA black box (2001) for QT prolongation and torsades based on older 25+ mg surgical-anesthesia and antiemetic doses; at modern 2.5-5 mg agitation doses with baseline EKG screening, recent ED literature (Calver 2015, Perkins 2015) shows safety profile comparable to haldol, and many EDs now use droperidol as the preferred parenteral antipsychotic for severe agitation. Pre-dose checks identical to haldol: EKG (QTc < 500), K, Mg. Same contraindications as haldol (Parkinson's, DLB, prior NMS).
Olanzapine (Zyprexa) IM SEDATION	5-10 mg IM (Zydis ODT also available for cooperative PO refuser). Max 30 mg/24h. Cap at 10 mg single dose in older adults.	15-45 min IM	More sedating than haldol or droperidol, useful when the dominant problem is the patient cannot rest. Do NOT combine with IM/IV lorazepam within 1 hour, FDA black box for cardiorespiratory depression and death (especially in elderly). Anticholinergic load at higher doses, hence the elderly cap.
Ziprasidone (Geodon) IM NON-PARKINSON ATYPICAL	10-20 mg IM, may repeat q4h. Max 40 mg/24h.	15-30 min IM	Useful when haldol is contraindicated for non-QT reasons (Parkinson's, prior NMS) and the patient is refusing PO. Less sedating than olanzapine, less anticholinergic. Caveat: ziprasidone has the highest QT-prolonging effect of the atypical antipsychotics, so it does NOT rescue you when QTc is the contraindication, the alternative for QT-prolonged patients is non-pharmacologic management plus level-of-care escalation.
Level-of-care escalation CALL FOR HELP	Rapid response → anesthesia → step-down or ICU transfer	Immediate	If 2-3 antipsychotics across 60-90 min have failed, stop and call. The diagnosis is probably wrong (re-run the mimic sweep, consider NMS, serotonin syndrome, status epilepticus, ICH, sepsis), or the patient needs continuous dexmedetomidine 0.2-1.5 mcg/kg/hr in a monitored setting, the only reliably escalatory pharmacologic option beyond bolus antipsychotics, and not appropriate for a regular medical floor. DahLIA, 2016: dex resolves agitated delirium faster than placebo in ventilated patients.

Ketamine 4-5 mg/kg IM (or 1-2 mg/kg IV slow) is NOT a ward order. Reserved for life-threatening agitation in monitored settings (ED, ICU, anesthesia present). Onset 3-5 min IM, dissociative. If you are reaching for ketamine on a regular medical floor, you needed to escalate level of care 30 minutes earlier. Cautions: laryngospasm (rare), hypersalivation (premedicate with glycopyrrolate), emergence reactions, BP/HR rise. Useful framing: "ketamine is the answer when the patient will hurt someone in the next 60 seconds, in a place where airway and ICU are seconds away."

The "B-52" cocktail (Haldol 5 mg + Lorazepam 2 mg + Benadryl 50 mg IM) is NOT appropriate on a medical ward for delirium. Diphenhydramine adds anticholinergic load (worsens delirium), lorazepam is harmful in non-withdrawal delirium, and the doses are 4–10× too high for an older inpatient. Patients who genuinely need that level of sedation need an ICU evaluation, not a ward IM cocktail.

Avoid IM olanzapine + IM/IV lorazepam together. FDA black box for cardiorespiratory depression and death, especially in elderly. Separate by ≥ 1 hour if both are genuinely needed.

Step 4, Physical Restraints (Last Resort)

Indication: imminent harm AND less-restrictive options have failed or are unsafe. Document both halves explicitly. Why: a chart that just says "patient agitated, restraints applied" doesn't meet CMS standards and is medico-legally exposed.
Order requirements: physician order, time-limited (CMS: 4 hours adults, 2 hours ages 9–17, 1 hour under 9), specific behaviors documented, less-restrictive alternatives tried documented. Renewal requires face-to-face evaluation.
Monitoring: circulation, skin integrity, range of motion, toileting, hydration q15 min initially. Why: restraint-related injuries (pressure, brachial plexus, asphyxia from prone restraint) are "never events" and the q15 min check is what catches them.
Mitts before 4-points. Mittens prevent line-pulling without immobilizing limbs. 4-point restraint is rarely necessary on a medical ward outside acute psychiatric emergencies.
Remove ASAP. Reassess at every nursing check, not just at order renewal. Why: every additional hour increases delirium duration, pressure injury, and aspiration risk.

Step 5, After the Event

Reassess in 30 minutes for response and side effects: dystonia, akathisia, hypotension, oversedation, EPS. Why: akathisia is commonly mistaken for "still agitated" → wrong response is to give more antipsychotic, which makes it worse.
Repeat EKG if cumulative haloperidol ≥ 2 mg or any other QT-prolonger on board.
Daily reassessment of need. Write a stop date on the antipsychotic order. Why: most ward antipsychotics started for delirium get discharged on the patient, leading to outpatient falls, CV events, and the FDA-warned mortality bump.
Document trigger identified (or "no clear trigger after sweep"), what was tried, what worked, what dose. Why: the next overnight team needs the playbook so they don't restart from zero at 3 AM.

3 AM Decision Tree, "Patient Is Agitated Right Now"

SpO₂, fingerstick, full vitals while you walk in.
Bladder scan if not done in last 6h. Rectal if no BM in 3 days.
CIWA + last-drink history if any tremor, tachycardia, HTN, or diaphoresis.
Pain assessment (verbal scale, or PAINAD if non-verbal).
Sensory aids on, lights up, sitter requested, family called.
If still agitated AND a danger to self or staff: Haldol 0.5 mg IV (or 0.25 mg if frail/very elderly). Re-evaluate in 30 min. Do not redose more frequently than q30 min without re-eval.
If haldol inadequate at 30 min: repeat once if cumulative < 3 mg AND EKG OK, OR switch agents, droperidol 2.5 mg IV (faster onset), olanzapine 5-10 mg IM (more sedation), ziprasidone 10-20 mg IM (when haldol contraindicated for Parkinson's). See escalation table above.
If 2-3 agents across 60-90 min have failed: stop, re-run mimic sweep, reconsider diagnosis (NMS, serotonin syndrome, status epilepticus, ICH, sepsis), and call rapid response, the patient needs ICU/step-down for dexmedetomidine, not more haldol.
If withdrawal: Lorazepam 1–2 mg IV + thiamine 100 mg IV (thiamine BEFORE glucose if EtOH).
Document trigger and response before you leave the room.

High-Yield Why-Pearls

The most dangerous moment in ward agitation is the order for sedation written before the SpO₂ is checked. Hypoxia and hypoglycemia look identical to delirium and they kill faster.
Every Foley pulled is one less reason to be agitated tomorrow. Untether early and often.
A 1:1 sitter is medicine. Restraints are a complication waiting to happen.
Haloperidol calms behavior; it does not treat delirium. The fix is the trigger, not the prescription.
Akathisia from haldol looks like "still agitated." Giving more makes it worse. Always consider EPS before redosing.
If you write for an antipsychotic, write the stop date in the same order. Every. Single. Time.

📋 On Rounds

What is the #1 modifiable risk factor for delirium?

Medications. The most common offenders: (1) Anticholinergics (diphenhydramine, oxybutynin, promethazine, cyclobenzaprine -check the Beers List), (2) Benzodiazepines (lorazepam, midazolam -strongly associated with delirium in ICU and elderly), (3) Opioids (especially meperidine -active metabolite normeperidine causes seizures and delirium), (4) Steroids (high-dose), (5) Polypharmacy (≥ 5 medications increases delirium risk independently).

What is the CAM-ICU and how does it differ from the regular CAM?

CAM-ICU is a validated delirium screening tool adapted for patients who cannot speak (intubated, nonverbal). It tests: (1) acute onset/fluctuation, (2) inattention (squeeze hand on letter 'A' in S-A-V-E-A-H-A-A-R-T -errors ≥ 2 = positive), (3) altered level of consciousness (RASS ≠ 0), (4) disorganized thinking (simple questions + commands). Delirium = features 1+2 plus either 3 or 4.

What is the HELP protocol and why does it work better than medications for delirium?

HELP (Hospital Elder Life Program) is a multicomponent non-pharmacologic intervention that reduces delirium incidence by 33-40%. Components: (1) Orientation: clocks, calendars, whiteboards with date/team names, familiar objects from home. (2) Sleep: lights off at night, minimize overnight vitals/labs/interruptions, warm milk/herbal tea, earplugs + eye masks

What is the role of antipsychotics in delirium?

Antipsychotics do NOT prevent or treat delirium -this was shown definitively by MIND, 2018 (haloperidol and ziprasidone vs placebo in ICU delirium) and AID-ICU, 2022 (haloperidol didn't reduce delirium days or mortality). Their only role: severe agitation that threatens patient or staff safety when non-pharmacologic measures have failed and the patient is pulling lines or at risk of self-harm.

Patient agitated overnight. What do you check before writing for haloperidol?

Run the 5-minute mimic sweep first. SpO₂ (hypoxia), fingerstick (hypoglycemia), tremor/HR/last-drink (alcohol or BZD withdrawal), bladder scan (retention), rectal/last-BM (impaction), pain assessment (under-treated pain). Also: hypercapnia in COPD/OSA, focal neuro signs in anticoagulated patients (head CT), rigidity + recent antipsychotic or serotonergic agent (NMS/SS). Sedating any of these without identifying them can kill, hypoxia and hypoglycemia look identical to delirium and crash faster.

Why is the "B-52" cocktail (Haldol 5 + Ativan 2 + Benadryl 50 IM) inappropriate on a medical ward?

Three reasons. (1) Diphenhydramine is anticholinergic and worsens delirium, the opposite of what you want. (2) Lorazepam is contraindicated in non-withdrawal delirium, it prolongs the episode via GABAergic disinhibition. (3) The doses are 4-10x too high for an older inpatient (haldol target is 0.25-0.5 mg, not 5 mg). The B-52 is an ED chemical-restraint cocktail for a young, otherwise healthy, severely agitated psychiatric patient, NOT a prescription for ward delirium. If a ward patient genuinely needs that level of sedation, they need ICU evaluation.

You gave 0.5 mg haldol IV 30 minutes ago. Patient is still restless and now pacing. Do you give more?

Not without ruling out akathisia first. Haldol-induced akathisia (subjective inner restlessness, inability to sit still, pacing) looks like persistent agitation, but giving more antipsychotic makes it worse. Treatment is the opposite: reduce or stop haldol, consider propranolol 10-20 mg PO or benztropine 1-2 mg if severe, switch to a lower-D2 agent like quetiapine if antipsychotic still needed. The akathisia trap is a top reason ward residents end up snowing patients with escalating doses chasing a side effect.

Patient remains agitated after 1 mg haldol IV. EKG, K, and Mg are fine. Akathisia ruled out. What's your next move?

Switch agents, do not just keep redosing haldol past ~3 mg. Three reasonable parenteral options: (1) Droperidol 2.5 mg IV/IM, faster IV onset (3-10 min) and slightly more sedating, same EKG checks as haldol; (2) Olanzapine 5-10 mg IM when more sedation is the goal (do NOT combine with IM/IV lorazepam within 1 hour, FDA black box); (3) Ziprasidone 10-20 mg IM when haldol is contraindicated for Parkinson's or prior NMS (note: ziprasidone has the most QT effect of atypicals, so it does NOT rescue you from a QT contraindication). If 2-3 agents fail across 60-90 min, the diagnosis is wrong or the patient needs ICU/step-down for a dex drip, call rapid response.

What is droperidol, and why does it carry an FDA black box warning?

Droperidol is a butyrophenone antipsychotic, same drug class as haloperidol, with faster IV onset (3-10 min vs 5-10 min) and more sedation per milligram. Mechanism: D2 antagonist with α-adrenergic blockade. The 2001 FDA black box for QT prolongation and torsades was based on case reports at older surgical-anesthesia and antiemetic doses (often > 25 mg, occasionally up to 50-100 mg). Modern agitation dosing is 2.5-5 mg with baseline EKG, K, Mg, and recent ED literature (Calver 2015, Perkins 2015) shows safety comparable to haldol at these doses. The drug was largely pulled from US hospitals after the black box, but has been making a steady comeback in EDs as the preferred parenteral antipsychotic for severe acute agitation. Same contraindications as haldol: Parkinson's disease, Lewy body dementia, prior NMS, QTc > 500.

Clinical Examples

📋 Case 1, Hyperactive Delirium in Post-Surgical Patient

Patient: 78M with mild dementia (baseline MMSE 22), POD 2 from hip fracture repair, found pulling at IV lines, yelling at staff, trying to climb out of bed at 2 AM. Received morphine PCA and diphenhydramine for sleep.

Key findings: HR 108, BP 162/94, Temp 37.2°C. Agitated, disoriented to place and time, unable to spell "WORLD" backwards. CAM positive. UA: positive for UTI. Medications: morphine, diphenhydramine (both high-risk).

Management:

Remove precipitants: Stop morphine PCA (switch to scheduled acetaminophen + low-dose oxycodone PRN). Stop diphenhydramine (strong anticholinergic)
Treat UTI with appropriate antibiotics
Non-pharmacologic measures: reorient frequently, mobilize early, sleep hygiene, glasses/hearing aids at bedside
For acute safety: haloperidol 0.5-1 mg IV/IM once. Check QTc first. Avoid in Parkinson or Lewy body dementia

Teaching point: Always remove offending medications (anticholinergics, benzodiazepines, opioids) before reaching for antipsychotics. The MIND Trial, 2018 showed antipsychotics do NOT treat delirium.

📋 Case 2, Hypoactive Delirium Missed on Rounds

Patient: 82F with CHF and CKD, admitted for pneumonia 4 days ago. Nursing notes: "sleeping most of day, not eating." Intern documents "oriented x3" based on brief interaction.

Key findings: Drowsy, slow to respond. Unable to list months backwards (inattention). Does not know she is in the hospital. CAM positive. RASS -2. Medications: lorazepam 0.5 mg HS, metoclopramide.

Management:

Stop lorazepam (benzodiazepines are a major delirium precipitant in elderly)
Stop metoclopramide (dopamine antagonist, can worsen delirium)
Check metabolic causes: BMP (hyponatremia, hypercalcemia, uremia), TSH, B12, blood cultures
Mobilize aggressively, ensure adequate nutrition, implement HELP protocol Inouye HELP, 1999

Teaching point: Hypoactive delirium is far more common (70% of cases) but frequently missed because patients are quiet. It carries worse prognosis than hyperactive delirium. Screen every elderly patient daily with CAM.

📋 Case 3, ICU Delirium in Ventilated Patient

Patient: 65M intubated for 4 days with ARDS from pneumonia. Nurse reports intermittent agitation and lethargy. RASS fluctuating between -1 and +2.

Key findings: CAM-ICU positive. Currently on propofol drip and fentanyl for sedation. No spontaneous breathing trial attempted today. Foley catheter and bilateral soft restraints in place.

Management:

Switch from propofol/benzodiazepine sedation to dexmedetomidine (associated with less delirium) SEDCOM, 2009
Implement ABCDEF bundle: A ssess pain · B oth SAT + SBT daily · C hoice of light sedation · D elirium screening BID · E arly mobility · F amily engagement
Target lightest sedation possible (RASS 0 to -1). Daily sedation vacation + spontaneous breathing trial
Remove Foley (independent risk factor for delirium). Remove restraints if safe

Teaching point: The ABCDEF bundle reduces ICU delirium, ventilator days, and mortality. Every day of delirium in the ICU independently increases mortality by 10%. Dexmedetomidine is preferred over benzodiazepines for sedation.

📣 Sample Presentation

One-Liner

"Mrs. Johnson is an 82-year-old with dementia admitted for UTI who is now acutely agitated, pulling at lines, not recognizing family. CAM positive (acute onset, inattention, disorganized thinking). Hyperactive delirium."

Key Points to Cover on Rounds

CAM positive -hyperactive delirium. Precipitant: UTI (on ceftriaxone day 2) + new environment + disrupted sleep. Medication review: Benadryl was ordered PRN sleep -discontinued (anticholinergic). Oxybutynin on home med list -held. Non-pharmacologic interventions: reorientation board, family at bedside, glasses and hearing aids in place, lights on during day/off at night, minimize tethers, PT mobilization. Bladder scan: no retention. Constipation: last BM 3 days ago → PEG 3350 + senna. Avoiding antipsychotics unless severe agitation threatening safety.

🧪 Workup

See the Overview and Management tabs for topic-specific diagnostic evaluation.

💊 Medications

Medications -Delirium

Non-pharmacologic interventions FIRST. Medications are second-line, reserved for severe agitation endangering patient or staff safety. No medication treats delirium -only addresses symptoms while you fix the cause.

Non-Pharmacologic (First-Line)

Reorientation: clock, calendar, familiar objects, consistent caregivers, windows for day/night cycle
Sleep hygiene: minimize nighttime vitals/interruptions, reduce noise, lights off at night, cluster care
Mobility: early ambulation, PT/OT, avoid bed rest. Remove tethers (telemetry, Foley, restraints) when possible
Sensory aids: hearing aids, glasses at bedside -sensory deprivation worsens delirium
Avoid restraints: increase agitation, worsen delirium, increase fall risk. Use 1:1 sitter instead.
Review medications: STOP deliriogenic drugs (anticholinergics, benzodiazepines, opioids, diphenhydramine, muscle relaxants)

Pharmacologic (Severe Agitation Only)

Drug	Dose	Route	Notes
Haloperidol (Haldol)	0.5-1 mg, repeat q30-60 min PRN	IV/IM	Low-dose antipsychotic for acute agitation. Avoid if QTc >500 ms. Check ECG before and after. Not FDA-approved for delirium but widely used.
Quetiapine (Seroquel)	12.5-50 mg PO BID-TID	PO	More sedating, useful for nighttime agitation. Lower EPS risk than haloperidol. Monitor QTc.
Dexmedetomidine (Precedex)	0.2-1.5 mcg/kg/hr IV	IV	Alpha-2 agonist. ICU setting for intubated patients. Maintains arousability. Reduces delirium duration vs benzodiazepines. Risk: bradycardia, hypotension.
Benzodiazepines AVOID	-	-	WORSEN delirium in most cases. Exception: alcohol withdrawal delirium and benzodiazepine withdrawal -benzodiazepines are treatment of choice for these specific etiologies.

⚡ Summary

Summary

Diagnosis

CAM: (1) Acute onset + fluctuating course, (2) Inattention, (3) Disorganized thinking, (4) Altered consciousness. Need 1+2 + either 3 or 4.

Prevention

HELP protocol: orientation, sleep hygiene, mobility, glasses/hearing aids, hydration, avoid tethers. Reduces delirium by 33-40%.

Med Review

Stop anticholinergics (diphenhydramine, oxybutynin), benzodiazepines, opioids (minimize), meperidine (never use in elderly).

Workup

Infection (UA, CXR, blood cultures), metabolic (BMP, glucose, Ca²⁺, TSH, ammonia), medications, urinary retention (bladder scan), constipation.

Treatment

Treat the cause. Non-pharm first. Antipsychotics (haloperidol 0.5-2 mg) ONLY for safety-threatening agitation. Don't prevent delirium MIND, 2018.

Subtypes

Hyperactive (agitated, pulling lines -easy to diagnose). Hypoactive (quiet, withdrawn -easy to MISS, worse prognosis). Mixed: fluctuates.

Acute Agitation

Workup before prescription: SpO₂, glucose, withdrawal, retention, pain, hypercapnia, intracranial event, NMS/SS. Verbal de-escalation + 1:1 sitter resolve most cases. Haldol 0.25–0.5 mg only if safety threatened. NO B-52 cocktail on the wards.

📄 One Pager

Delirium & Altered Mental Status -Quick Reference Card

Print this page (Ctrl/Cmd + P) for a condensed reference card. All tabs will print on the same page for a complete topic summary.

DELIRIUM & ALTERED MENTAL STATUS -AT A GLANCE

📋 Diagnose: CAM positive (acute + fluctuating + inattention + either disorganized thinking or altered LOC) → see Overview tab
🧪 Workup: AEIOU TIPS, focused labs + imaging → see Workup tab
⚡ Treat: Non-pharm first (HELP protocol), find and fix the trigger → see Management tab
⚠️ Acute agitation: 5-min mimic sweep (SpO₂, glucose, withdrawal, retention, pain) BEFORE any sedative; verbal de-escalation + 1:1 sitter; haldol 0.25–0.5 mg only if safety threatened → see Acute Agitation tab
💊 Drugs: Haldol first-line, quetiapine for Parkinson's or DLB, NO benzos except for withdrawal, seizure, catatonia, NMS, or SS → see Medications tab
📣 Present: One-liner + key points → see Rounds tab