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 (next section).

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.

📋 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.

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) MENDS, 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.

📄 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: See Overview tab for criteria
🧪 Workup: Focused labs + imaging → see Workup tab
⚡ Treat: Evidence-based algorithm → see Management tab
💊 Drugs: Key medications with dosing → see Medications tab
📣 Present: One-liner + key points → see Rounds tab