Acute Confusion and DeliriumAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

729 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Transient Neurologic Deficits Acute Aphasia And Speech Disturbance Acute Confusion And Delirium Postictal State And Seizure Recurrence Concern Seizure Acute Vision Loss New Tremor And Involuntary Movements Headache Vertigo Acute Weakness Or Numbness Gait Instability And Ataxia

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx72

Presenting features and course

›Confusion and delirium history

›Time of onset

›Time course

›Minutes to hours

›Hours to days

›Days to weeks

›Fluctuating course

›Baseline cognition and function

›Prior episodes

›Precipitating context

›Recent illness

›Recent hospitalization

›Recent surgery or anesthesia

›Fall or head trauma

›Environmental change

›Sleep disruption

Symptom characterization

›Delirium features

›Inattention

›Disorganized thinking

›Altered level of consciousness

›Perceptual disturbance

›Visual hallucinations

›Auditory hallucinations

›Psychomotor change

›Hyperactive

›Hypoactive

›Mixed

OPQRST

›OPQRST not primary framework

›Delirium is a syndrome with fluctuating attention and awareness

›Focus on time course, triggers, and reversible causes

Associated symptoms

›Associated symptoms

›Fever

›Chills

›Headache

›Neck pain

›Photophobia

›New focal neurologic symptoms

›Seizure activity

›Chest pain

›Dyspnea

›Abdominal pain

›Vomiting

›Dysuria

›Urinary retention

›New incontinence

›Rash

›Recent weight loss

›Polyuria

›Polydipsia

Substance and exposure history

›Exposures

›Alcohol use pattern

›Recent alcohol cessation

›Benzodiazepine use pattern

›Recent benzodiazepine cessation

›Opioid exposure

›Cannabis exposure

›Stimulant exposure

›Cocaine

›Methamphetamine

›Toxin exposure

›Carbon monoxide

›Ethylene glycol

›Methanol

›Over the counter exposure

›Antihistamines

›Dextromethorphan

›Sleep aids

›Infectious exposure

›Sick contacts

›Recent travel

›Animal exposure

›Tick exposure

02Alarm Features/alarm45

Immediate escalation triggers

›Resuscitation triggers

›Airway compromise

›Hypoxia

›SpO2 < 90%

›Rising oxygen requirement

›Hypotension

›SBP < 90 mmHg

›MAP < 65 mmHg

›Severe hyperthermia

›Temperature >= 40.0 C

›Hypothermia

›Temperature < 35.0 C

›Hypoglycemia

›Glucose < 3.0 mmol/L

›New seizure

›Persistent seizure activity

›Marked agitation with unsafe behavior

›Suspected meningitis or encephalitis

›Fever

›Neck stiffness

›Purpura

›Suspected stroke

›New focal deficit

›Aphasia

›Neglect

›Suspected increased intracranial pressure

›Cushing response

›Papilledema

›Suspected toxidrome

›Cholinergic

›Anticholinergic

›Sympathomimetic

›Opioid

High risk populations

›High risk groups

›Age >= 65 years

›Immunocompromised

›Chemotherapy

›Transplant

›Chronic steroids

›Pregnancy

›Dialysis

›Cirrhosis

›Anticoagulated

›Baseline dementia

›Known seizure disorder

03Medications/meds34

Medication contributors

›High risk medication classes

›Anticholinergics

›Diphenhydramine

›Tricyclic antidepressants

›Oxybutynin

›Benzodiazepines

›Opioids

›Antipsychotics

›Sedative hypnotics

›Z drugs

›Corticosteroids

›Dopaminergic agents

›Antiepileptics

›Lithium

›Digoxin

›Insulin

›Sulfonylureas

›Beta blockers

›Clonidine

Medication changes and adherence

›Recent medication changes

›New start within 14 days

›Dose increase within 14 days

›Abrupt discontinuation

›Adherence pattern

›Missed doses

›Double dosing

›Pharmacy refill gaps

Contraindications to likely therapies

›Sedation risk modifiers

›Severe COPD

›Obstructive sleep apnea

›QT prolongation history

›Parkinson disease

›Lewy body dementia

›Myasthenia gravis

04Diet/diet12

Intake and hydration

›Nutrition and hydration

›Reduced oral intake

›Dehydration indicators

›Poor intake for > 24 hours

›Vomiting

›Diarrhea

›Caffeine intake change

›Energy drink exposure

›Recent alcohol intake change

›High free water intake

›Polydipsia

›Hypotonic fluids

05Review of Systems/ros39

System based symptoms

›ROS clusters

›Constitutional

›Fever

›Weight loss

›Night sweats

›Neurologic

›Headache

›Focal weakness

›Sensory change

›Vision change

›Speech change

›Gait instability

›Seizure

›Syncope

›Respiratory

›Dyspnea

›Cough

›Pleuritic pain

›Cardiovascular

›Chest pain

›Palpitations

›Gastrointestinal

›Abdominal pain

›Vomiting

›Diarrhea

›Constipation

›Genitourinary

›Dysuria

›Frequency

›Flank pain

›Urinary retention

›Endocrine

›Polyuria

›Polydipsia

›Heat intolerance

›Skin

›Rash

›Petechiae

›Jaundice

06Collateral History and Family History/chafh21

Collateral and baseline

›Collateral history

›Source

›Family

›Caregiver

›EMS

›Facility staff

›Reliability

›Direct witness

›Secondhand report

›Baseline cognition

›Dementia diagnosis

›Prior cognitive testing

›Baseline function

›Independent ADLs

›Assistance for ADLs

Family history

›Family history

›Dementia

›Parkinson disease

›Seizure disorder (G40.909)

›Early stroke (I63.9)

›Inherited metabolic disorders

07Risk Factors/rf27

Predisposition and precipitants

›Delirium risk factors

›Age >= 65 years

›Baseline cognitive impairment

›Sensory impairment

›Vision impairment

›Hearing impairment

›Polypharmacy

›>= 5 medications

›Dehydration

›Infection risk

›Indwelling urinary catheter

›Recent pneumonia

›Substance withdrawal risk

›Alcohol

›Benzodiazepines

›Sleep deprivation

›Recent surgery

›Pain undertreatment

›Frailty

Exposure and environment

›Exposure risks

›Carbon monoxide exposure

›Indoor combustion source

›Multiple symptomatic contacts

›Toxic ingestion access

›Medication access errors

›Blister pack change

›New caregiver

08Differential Diagnosis/ddx84

Life threatening

›Life threatening causes

›Hypoglycemia (E16.2)

›Diaphoresis

›Rapid improvement after glucose

›CNS infection

›Meningitis (G00.9)

›Encephalitis (G04.90)

›Fever

›Neck stiffness

›Immunocompromised

›Stroke

›Ischemic stroke (I63.9)

›Intracranial hemorrhage (I62.9)

›New focal deficit

›Severe headache

›Status epilepticus (G41.9)

›Witnessed convulsions

›Subtle automatisms

›Sepsis (A41.9)

›Hypotension

›Lactate elevation

›Hypercapnic encephalopathy

›COPD exacerbation (J44.1)

›Somnolence

›Elevated CO2 on VBG or ABG

›Hypoxic encephalopathy

›Hypoxia

›Respiratory failure

›Toxicologic emergency

›Opioid toxicity (T40.2X1A)

›Anticholinergic toxicity

›Serotonin syndrome (T43.201A)

›Neuroleptic malignant syndrome (G21.0)

›Hypertensive emergency encephalopathy (I16.1)

›Severe hypertension with end organ dysfunction

›Wernicke encephalopathy (E51.2)

›Malnutrition

›Alcohol use disorder

Common

›Common causes

›UTI related delirium

›Bacteriuria with symptoms

›Alternative source search if no urinary symptoms

›Pneumonia (J18.9)

›Cough

›Hypoxia

›Medication effect

›Recent sedative start

›Anticholinergic burden

›Dehydration

›Poor intake

›Orthostasis

›Electrolyte disturbance

›Hyponatremia (E87.1)

›Hypernatremia (E87.0)

›Hypercalcemia (E83.52)

›Acute kidney injury (N17.9)

›Uremia

›Medication accumulation

›Hepatic encephalopathy (K72.90)

›Cirrhosis

›Asterixis

Less common

›Less common causes

›Thyroid storm (E05.91)

›Hyperthermia

›Tachycardia

›Myxedema coma (E03.5)

›Hypothermia

›Bradycardia

›Adrenal crisis (E27.2)

›Hypotension

›Hyperkalemia

›DKA or HHS

›DKA (E10.10)

›HHS (E11.00)

›Subdural hematoma (I62.00)

›Fall history

›Anticoagulation

›CNS tumor with acute decompensation (C71.9)

›Autoimmune encephalitis

›New psychiatric symptoms

›Seizure

›Nonconvulsive status epilepticus

›Persistent altered consciousness

›Subtle twitching

09Past Medical History/pmh27

Baseline conditions

›Relevant PMH

›Dementia (F03.90)

›Baseline orientation

›Baseline supervision needs

›Parkinson disease (G20)

›Dopaminergic medications

›Sensitivity to antipsychotics

›Prior stroke or TIA (I63.9)

›Baseline deficits

›Antithrombotic therapy

›Seizure disorder (G40.909)

›Last seizure date

›Antiepileptic adherence

›Alcohol use disorder (F10.20)

›Prior withdrawal complications

›Prior seizures or DTs

›CKD (N18.9)

›Dialysis schedule

›Baseline creatinine

›Cirrhosis (K74.60)

›Prior encephalopathy

›Lactulose use

Devices and recent care

›Prior procedures and devices

›Indwelling urinary catheter

›Central venous catheter

›Ventriculoperitoneal shunt

›Implanted cardiac device

10Physical Exam/exam68

General and vitals

›General assessment

›Toxic appearance

›Hydration

›Dry mucous membranes

›Poor skin turgor

›Work of breathing

›Odor

›Alcohol

›Ketones

›Vital signs pattern

›Fever

›Hypothermia

›Tachycardia

›Bradycardia

›Hypertension

›Hypotension

›Tachypnea

›Hypoxia

Mental status and neurologic

›Cognitive and neurologic exam

›Level of consciousness

›Alert

›Drowsy

›Stuporous

›Attention testing

›Months backward

›Digit span

›Orientation

›Person

›Place

›Time

›Speech and language

›Dysarthria

›Aphasia

›Cranial nerves

›Motor

›Pronator drift

›Asymmetry

›Sensory

›Coordination

›Finger nose

›Heel shin

›Gait if safe

›Meningeal signs

›Nuchal rigidity

›Kernig

›Brudzinski

›Tremor and rigidity

›Asterixis

Cardiopulmonary and other systems

›Systems exam

›Cardiovascular

›New murmur

›Irregular rhythm

›Respiratory

›Focal crackles

›Wheeze

›Abdomen

›Tenderness

›Ascites

›Skin

›Petechiae

›Purpura

›Track marks

›Head and trauma

›Scalp hematoma

›Signs of basilar skull fracture

›Bladder

›Suprapubic distension

›Bladder scan volume

11Lab Studies/labs53

Bedside and core labs

›Initial labs

›Point of care glucose

›Hypoglycemia threshold < 3.0 mmol/L

›Recheck after treatment

›CBC

›Leukocytosis

›Anemia

›Electrolytes

›Sodium

›Potassium

›Calcium

›Magnesium

›Renal function

›Creatinine

›Urea

›Liver panel

›AST

›ALT

›Bilirubin

›Alkaline phosphatase

›VBG or ABG if respiratory concern

›pH

›CO2 in mmHg

›Lactate if sepsis concern

›Repeat within 2 to 4 hours if elevated

›Interpret with perfusion and beta agonists

Focused tests by suspicion

›Targeted labs

›Urinalysis

›Interpret with symptoms

›Asymptomatic bacteriuria does not confirm cause

›Blood cultures

›Before antibiotics if sepsis

›Two sets preferred

›Toxicology

›Acetaminophen level

›Salicylate level

›Ethanol level

›Urine drug screen limitations

›CK

›If rigidity

›If hyperthermia

›TSH and free T4

›If hypo or hyperthyroid concern

›Not routine in clear alternative cause

›Ammonia

›If cirrhosis with suspected hepatic encephalopathy

›Poor correlation with severity

›Troponin

›If ischemia concern

›Serial timing local protocol dependent

›Pregnancy test

›All patients with pregnancy potential

›Before radiating imaging when possible

12Imaging/img37

Scoring Systems

›Delirium identification tools

›Confusion Assessment Method

›Acute onset and fluctuating course

›Inattention

›Disorganized thinking

›Altered level of consciousness

›4AT

›Alertness

›AMT4

›Attention

›Acute change or fluctuating course

MRI

›MRI brain

›Indications

›Suspected posterior circulation stroke with nondiagnostic CT

›Suspected encephalitis with nondiagnostic CT and LP

›Considerations

›Time to imaging

›MRI contraindications

›Some implanted devices

›Metallic foreign body

›CT head

›Indications

›New focal neurologic deficit

›Head trauma

›Anticoagulation with fall

›Severe headache

›Suspected intracranial hemorrhage

›Pitfalls

›Early ischemic stroke can be CT negative

›Delirium without focal findings often has low diagnostic yield

Ultrasound

›POCUS

›Bladder scan

›Urinary retention as reversible cause

›Post void residual assessment

›Lung ultrasound

›B lines for pulmonary edema

›Consolidation patterns for pneumonia

13Special Tests/spec21

Procedures and bedside assessments

›Lumbar puncture

›Indications

›Suspected meningitis

›Suspected encephalitis

›Pre LP imaging triggers

›New focal deficit

›Immunocompromised

›Known CNS lesion

›Papilledema

›EEG access pathway

›Indications

›Suspected nonconvulsive status epilepticus

›Persistent unexplained altered mental status

›Limitations

›Limited availability in some EDs

›Intermittent seizures can be missed on short recordings

Cognitive screening and delirium monitoring

›Serial mental status checks

›Repeat attention testing

›Fluctuation documentation interval

›Every 30 to 60 minutes in unstable

›Every 2 to 4 hours in stable

14ECG/ecg16

Indications and high risk patterns

›ECG use in delirium

›Syncope or presyncope

›Chest pain

›Palpitations

›Electrolyte disturbance

›Antipsychotic or QT prolonging medication use

›High risk findings

›ST elevation

›New ST depression

›New T wave inversion

›Wide QRS

›QTc prolongation

›QTc >= 500 ms

›Avoid QT prolonging sedatives if possible

›High grade AV block

›Ventricular arrhythmia

15Assessment/ax18

Syndrome framing and severity

›Working diagnosis structure

›Delirium due to medical condition

›Hypoactive subtype risk for missed diagnosis

›Identify precipitant and vulnerability factors

›Primary psychiatric disorder as diagnosis of exclusion

›After medical and toxicologic causes addressed

›Severity and risk

›Hyperactive delirium with safety risk

›Hypoactive delirium with aspiration risk

›High risk etiologies under evaluation

›CNS infection

›Stroke

›Sepsis

Key support for diagnosis

›Supporting features

›Acute change from baseline

›Fluctuating course

›Inattention on bedside testing

›Disorganized thinking

16Plan/plan97

First 5 minutes

›Immediate stabilization

›Airway support if unable to protect airway

›Oxygen if hypoxic

›Target SpO2 92% to 96%

›Target SpO2 88% to 92% in chronic hypercapnia risk

›Cardiac monitor if unstable

›IV access criteria

›Hypotension

›Suspected sepsis

›Need for IV sedation

›Point of care glucose immediately

›Temperature measurement

›Deescalation environment

›Low stimulation

›Reorientation cues

Diagnostic sequencing

›Diagnostic priorities

›Reversible physiologic derangements first

›Hypoxia

›Hypoglycemia

›Hypercapnia

›Hypotension

›Infection evaluation by syndrome

›Urinary

›Pulmonary

›Skin

›Abdominal

›Neuro emergency evaluation when indicated

›Stroke pathway if focal findings

›CT head triggers present

›LP pathway if CNS infection concern

›Toxicologic evaluation when indicated

›Acetaminophen

›Salicylates

›Alcohol withdrawal risk assessment

Therapeutic plan

›Non pharmacologic measures

›Treat pain

›Ensure glasses and hearing aids

›Hydration correction

›Sleep promotion

›Avoid overnight disruptions when safe

›Agitation and dangerous behavior

›Initial approach

›Verbal de escalation

›One staff spokesperson

›Chemical sedation

›Haloperidol IV 0.5 mg

›Repeat 0.5 mg every 15 to 30 minutes to effect

›Typical total 1 mg to 5 mg

›Avoid in Parkinson disease

›Avoid in Lewy body dementia

›QTc monitoring

›Olanzapine IM 5 mg

›Repeat 5 mg after 2 hours if needed

›Maximum 10 mg in 24 hours in frail older adults local protocol dependent

›Avoid with benzodiazepines within 1 hour due to respiratory depression risk local protocol dependent

›Lorazepam IV 0.5 mg

›Preferred for alcohol withdrawal

›Repeat 0.5 mg to 1 mg every 10 to 20 minutes to effect

›Paradoxical disinhibition risk in older adults

›Ketamine IV 0.5 mg/kg

›Severe agitation with imminent harm

›Monitor for hypertension

›Monitor for hypersalivation

›Physical restraints

›Only as bridge to chemical sedation

›Continuous observation required

›Alcohol withdrawal treatment

›Thiamine IV 200 mg

›Give before glucose containing fluids when possible

›Repeat daily for 3 days if high risk

›Benzodiazepines

›Symptom triggered protocol local protocol dependent

›Escalation to ICU if refractory

Monitoring and reassessment

›Reassessment loop

›Vitals frequency

›Every 5 to 15 minutes during sedation

›Every 30 to 60 minutes when unstable

›Repeat mental status

›After each intervention

›After test results return

›Delirium contributors review

›New meds

›Urinary retention

›Constipation

›Pain

›Hypoxia

›Consultation triggers

›Neurology

›Suspected stroke

›Suspected nonconvulsive status epilepticus

›ICU

›Airway risk

›Refractory agitation

›Hypercapnia requiring ventilatory support

›Internal medicine or geriatrics

›Persistent delirium

›Frailty with unclear precipitant

17Disposition/dispo29

Level of care criteria

›ICU indications

›Need for ventilatory support

›Vasopressor requirement

›Status epilepticus

›Severe sepsis with shock

›Refractory agitation requiring continuous sedation

›Inpatient admission indications

›Persistent delirium without identified reversible cause in ED

›New serious diagnosis

›Pneumonia

›Sepsis

›Stroke

›CNS infection

›Unsafe discharge environment

›No reliable supervision

›High fall risk

›Need for IV therapy

›IV antibiotics

›IV fluids with monitoring

›Observation pathway

›Transient delirium with reversible cause treated

›Need for short interval reassessment after sedation

›Mild infection treated with stable vitals

›Discharge criteria

›Return to baseline cognition

›Vitals stable for 2 to 4 hours

›Reversible cause treated or ruled out with a plan

›Reliable caregiver present

›Clear follow up within 24 to 72 hours

18Discharge Instructions/di22

Copy discharge instructions

›Discharge instructions

›Today you were seen for confusion

›Your symptoms were consistent with delirium

›Delirium can come and go and is often caused by a medical problem

›Take your medications exactly as prescribed

›Do not drink alcohol

›Do not use recreational drugs

›Do not drive until you are back to normal and cleared if needed

›Drink fluids regularly unless you were told to restrict fluids

›Arrange supervision by a trusted adult for the next 24 hours

›Follow up with your family doctor within 1 to 3 days

›Return to the emergency department now for any of the following

›Fever

›Worsening confusion

›New weakness

›Trouble speaking

›Severe headache

›Seizure

›Fainting

›Chest pain

›Trouble breathing

›Inability to keep fluids down

19References/r7

Guidelines and tools

›Core references

›American Geriatrics Society clinical practice guideline for postoperative delirium in older adults, 2015

›NICE Delirium prevention diagnosis and management guideline, 2019 update

›Society of Critical Care Medicine PADIS guidelines for pain agitation delirium immobility and sleep disruption, 2018

›IDSA guidelines for bacterial meningitis management, 2004 with local protocol dependent updates

›AHA ASA acute ischemic stroke guidelines, 2019 update

›Confusion Assessment Method validation studies, original and subsequent validation cohorts

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Acute Confusion and DeliriumAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

729 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx72

Presenting features and course

›Confusion and delirium history

›Time of onset

›Time course

›Minutes to hours

›Hours to days

›Days to weeks

›Fluctuating course

›Baseline cognition and function

›Prior episodes

›Precipitating context

›Recent illness

›Recent hospitalization

›Recent surgery or anesthesia

›Fall or head trauma

›Environmental change

›Sleep disruption

Symptom characterization

›Delirium features

›Inattention

›Disorganized thinking

›Altered level of consciousness

›Perceptual disturbance

›Visual hallucinations

›Auditory hallucinations

›Psychomotor change

›Hyperactive

›Hypoactive

›Mixed

OPQRST

›OPQRST not primary framework

›Delirium is a syndrome with fluctuating attention and awareness

›Focus on time course, triggers, and reversible causes

Associated symptoms

›Associated symptoms

›Fever

›Chills

›Headache

›Neck pain

›Photophobia

›New focal neurologic symptoms

›Seizure activity

›Chest pain

›Dyspnea

›Abdominal pain

›Vomiting

›Dysuria

›Urinary retention

›New incontinence

›Rash

›Recent weight loss

›Polyuria

›Polydipsia

Substance and exposure history

›Exposures

›Alcohol use pattern

›Recent alcohol cessation

›Benzodiazepine use pattern

›Recent benzodiazepine cessation

›Opioid exposure

›Cannabis exposure

›Stimulant exposure

›Cocaine

›Methamphetamine

›Toxin exposure

›Carbon monoxide

›Ethylene glycol

›Methanol

›Over the counter exposure

›Antihistamines

›Dextromethorphan

›Sleep aids

›Infectious exposure

›Sick contacts

›Recent travel

›Animal exposure

›Tick exposure

02Alarm Features/alarm45

Immediate escalation triggers

›Resuscitation triggers

›Airway compromise

›Hypoxia

›SpO2 < 90%

›Rising oxygen requirement

›Hypotension

›SBP < 90 mmHg

›MAP < 65 mmHg

›Severe hyperthermia

›Temperature >= 40.0 C

›Hypothermia

›Temperature < 35.0 C

›Hypoglycemia

›Glucose < 3.0 mmol/L

›New seizure

›Persistent seizure activity

›Marked agitation with unsafe behavior

›Suspected meningitis or encephalitis

›Fever

›Neck stiffness

›Purpura

›Suspected stroke

›New focal deficit

›Aphasia

›Neglect

›Suspected increased intracranial pressure

›Cushing response

›Papilledema

›Suspected toxidrome

›Cholinergic

›Anticholinergic

›Sympathomimetic

›Opioid

High risk populations

›High risk groups

›Age >= 65 years

›Immunocompromised

›Chemotherapy

›Transplant

›Chronic steroids

›Pregnancy

›Dialysis

›Cirrhosis

›Anticoagulated

›Baseline dementia

›Known seizure disorder

03Medications/meds34

Medication contributors

›High risk medication classes

›Anticholinergics

›Diphenhydramine

›Tricyclic antidepressants

›Oxybutynin

›Benzodiazepines

›Opioids

›Antipsychotics

›Sedative hypnotics

›Z drugs

›Corticosteroids

›Dopaminergic agents

›Antiepileptics

›Lithium

›Digoxin

›Insulin

›Sulfonylureas

›Beta blockers

›Clonidine

Medication changes and adherence

›Recent medication changes

›New start within 14 days

›Dose increase within 14 days

›Abrupt discontinuation

›Adherence pattern

›Missed doses

›Double dosing

›Pharmacy refill gaps

Contraindications to likely therapies

›Sedation risk modifiers

›Severe COPD

›Obstructive sleep apnea

›QT prolongation history

›Parkinson disease

›Lewy body dementia

›Myasthenia gravis

04Diet/diet12

Intake and hydration

›Nutrition and hydration

›Reduced oral intake

›Dehydration indicators

›Poor intake for > 24 hours

›Vomiting

›Diarrhea

›Caffeine intake change

›Energy drink exposure

›Recent alcohol intake change

›High free water intake

›Polydipsia

›Hypotonic fluids

05Review of Systems/ros39

System based symptoms

›ROS clusters

›Constitutional

›Fever

›Weight loss

›Night sweats

›Neurologic

›Headache

›Focal weakness

›Sensory change

›Vision change

›Speech change

›Gait instability

›Seizure

›Syncope

›Respiratory

›Dyspnea

›Cough

›Pleuritic pain

›Cardiovascular

›Chest pain

›Palpitations

›Gastrointestinal

›Abdominal pain

›Vomiting

›Diarrhea

›Constipation

›Genitourinary

›Dysuria

›Frequency

›Flank pain

›Urinary retention

›Endocrine

›Polyuria

›Polydipsia

›Heat intolerance

›Skin

›Rash

›Petechiae

›Jaundice

06Collateral History and Family History/chafh21

Collateral and baseline

›Collateral history

›Source

›Family

›Caregiver

›EMS

›Facility staff

›Reliability

›Direct witness

›Secondhand report

›Baseline cognition

›Dementia diagnosis

›Prior cognitive testing

›Baseline function

›Independent ADLs

›Assistance for ADLs

Family history

›Family history

›Dementia

›Parkinson disease

›Seizure disorder (G40.909)

›Early stroke (I63.9)

›Inherited metabolic disorders

07Risk Factors/rf27

Predisposition and precipitants

›Delirium risk factors

›Age >= 65 years

›Baseline cognitive impairment

›Sensory impairment

›Vision impairment

›Hearing impairment

›Polypharmacy

›>= 5 medications

›Dehydration

›Infection risk

›Indwelling urinary catheter

›Recent pneumonia

›Substance withdrawal risk

›Alcohol

›Benzodiazepines

›Sleep deprivation

›Recent surgery

›Pain undertreatment

›Frailty

Exposure and environment

›Exposure risks

›Carbon monoxide exposure

›Indoor combustion source

›Multiple symptomatic contacts

›Toxic ingestion access

›Medication access errors

›Blister pack change

›New caregiver

08Differential Diagnosis/ddx84

Life threatening

›Life threatening causes

›Hypoglycemia (E16.2)

›Diaphoresis

›Rapid improvement after glucose

›CNS infection

›Meningitis (G00.9)

›Encephalitis (G04.90)

›Fever

›Neck stiffness

›Immunocompromised

›Stroke

›Ischemic stroke (I63.9)

›Intracranial hemorrhage (I62.9)

›New focal deficit

›Severe headache

›Status epilepticus (G41.9)

›Witnessed convulsions

›Subtle automatisms

›Sepsis (A41.9)

›Hypotension

›Lactate elevation

›Hypercapnic encephalopathy

›COPD exacerbation (J44.1)

›Somnolence

›Elevated CO2 on VBG or ABG

›Hypoxic encephalopathy

›Hypoxia

›Respiratory failure

›Toxicologic emergency

›Opioid toxicity (T40.2X1A)

›Anticholinergic toxicity

›Serotonin syndrome (T43.201A)

›Neuroleptic malignant syndrome (G21.0)

›Hypertensive emergency encephalopathy (I16.1)

›Severe hypertension with end organ dysfunction

›Wernicke encephalopathy (E51.2)

›Malnutrition

›Alcohol use disorder

Common

›Common causes

›UTI related delirium

›Bacteriuria with symptoms

›Alternative source search if no urinary symptoms

›Pneumonia (J18.9)

›Cough

›Hypoxia

›Medication effect

›Recent sedative start

›Anticholinergic burden

›Dehydration

›Poor intake

›Orthostasis

›Electrolyte disturbance

›Hyponatremia (E87.1)

›Hypernatremia (E87.0)

›Hypercalcemia (E83.52)

›Acute kidney injury (N17.9)

›Uremia

›Medication accumulation

›Hepatic encephalopathy (K72.90)

›Cirrhosis

›Asterixis

Less common

›Less common causes

›Thyroid storm (E05.91)

›Hyperthermia

›Tachycardia

›Myxedema coma (E03.5)

›Hypothermia

›Bradycardia

›Adrenal crisis (E27.2)

›Hypotension

›Hyperkalemia

›DKA or HHS

›DKA (E10.10)

›HHS (E11.00)

›Subdural hematoma (I62.00)

›Fall history

›Anticoagulation

›CNS tumor with acute decompensation (C71.9)

›Autoimmune encephalitis

›New psychiatric symptoms

›Seizure

›Nonconvulsive status epilepticus

›Persistent altered consciousness

›Subtle twitching

09Past Medical History/pmh27

Baseline conditions

›Relevant PMH

›Dementia (F03.90)

›Baseline orientation

›Baseline supervision needs

›Parkinson disease (G20)

›Dopaminergic medications

›Sensitivity to antipsychotics

›Prior stroke or TIA (I63.9)

›Baseline deficits

›Antithrombotic therapy

›Seizure disorder (G40.909)

›Last seizure date

›Antiepileptic adherence

›Alcohol use disorder (F10.20)

›Prior withdrawal complications

›Prior seizures or DTs

›CKD (N18.9)

›Dialysis schedule

›Baseline creatinine

›Cirrhosis (K74.60)

›Prior encephalopathy

›Lactulose use

Devices and recent care

›Prior procedures and devices

›Indwelling urinary catheter

›Central venous catheter

›Ventriculoperitoneal shunt

›Implanted cardiac device

10Physical Exam/exam68

General and vitals

›General assessment

›Toxic appearance

›Hydration

›Dry mucous membranes

›Poor skin turgor

›Work of breathing

›Odor

›Alcohol

›Ketones

›Vital signs pattern

›Fever

›Hypothermia

›Tachycardia

›Bradycardia

›Hypertension

›Hypotension

›Tachypnea

›Hypoxia

Mental status and neurologic

›Cognitive and neurologic exam

›Level of consciousness

›Alert

›Drowsy

›Stuporous

›Attention testing

›Months backward

›Digit span

›Orientation

›Person

›Place

›Time

›Speech and language

›Dysarthria

›Aphasia

›Cranial nerves

›Motor

›Pronator drift

›Asymmetry

›Sensory

›Coordination

›Finger nose

›Heel shin

›Gait if safe

›Meningeal signs

›Nuchal rigidity

›Kernig

›Brudzinski

›Tremor and rigidity

›Asterixis

Cardiopulmonary and other systems

›Systems exam

›Cardiovascular

›New murmur

›Irregular rhythm

›Respiratory

›Focal crackles

›Wheeze

›Abdomen

›Tenderness

›Ascites

›Skin

›Petechiae

›Purpura

›Track marks

›Head and trauma

›Scalp hematoma

›Signs of basilar skull fracture

›Bladder

›Suprapubic distension

›Bladder scan volume

11Lab Studies/labs53

Bedside and core labs

›Initial labs

›Point of care glucose

›Hypoglycemia threshold < 3.0 mmol/L

›Recheck after treatment

›CBC

›Leukocytosis

›Anemia

›Electrolytes

›Sodium

›Potassium

›Calcium

›Magnesium

›Renal function

›Creatinine

›Urea

›Liver panel

›AST

›ALT

›Bilirubin

›Alkaline phosphatase

›VBG or ABG if respiratory concern

›pH

›CO2 in mmHg

›Lactate if sepsis concern

›Repeat within 2 to 4 hours if elevated

›Interpret with perfusion and beta agonists

Focused tests by suspicion

›Targeted labs

›Urinalysis

›Interpret with symptoms

›Asymptomatic bacteriuria does not confirm cause

›Blood cultures

›Before antibiotics if sepsis

›Two sets preferred

›Toxicology

›Acetaminophen level

›Salicylate level

›Ethanol level

›Urine drug screen limitations

›CK

›If rigidity

›If hyperthermia

›TSH and free T4

›If hypo or hyperthyroid concern

›Not routine in clear alternative cause

›Ammonia

›If cirrhosis with suspected hepatic encephalopathy

›Poor correlation with severity

›Troponin

›If ischemia concern

›Serial timing local protocol dependent

›Pregnancy test

›All patients with pregnancy potential

›Before radiating imaging when possible

12Imaging/img37

Scoring Systems

›Delirium identification tools

›Confusion Assessment Method

›Acute onset and fluctuating course

›Inattention

›Disorganized thinking

›Altered level of consciousness

›4AT

›Alertness

›AMT4

›Attention

›Acute change or fluctuating course

MRI

›MRI brain

›Indications

›Suspected posterior circulation stroke with nondiagnostic CT

›Suspected encephalitis with nondiagnostic CT and LP

›Considerations

›Time to imaging

›MRI contraindications

›Some implanted devices

›Metallic foreign body

›CT head

›Indications

›New focal neurologic deficit

›Head trauma

›Anticoagulation with fall

›Severe headache

›Suspected intracranial hemorrhage

›Pitfalls

›Early ischemic stroke can be CT negative

›Delirium without focal findings often has low diagnostic yield

Ultrasound

›POCUS

›Bladder scan

›Urinary retention as reversible cause

›Post void residual assessment

›Lung ultrasound

›B lines for pulmonary edema

›Consolidation patterns for pneumonia

13Special Tests/spec21

Procedures and bedside assessments

›Lumbar puncture

›Indications

›Suspected meningitis

›Suspected encephalitis

›Pre LP imaging triggers

›New focal deficit

›Immunocompromised

›Known CNS lesion

›Papilledema

›EEG access pathway

›Indications

›Suspected nonconvulsive status epilepticus

›Persistent unexplained altered mental status

›Limitations

›Limited availability in some EDs

›Intermittent seizures can be missed on short recordings

Cognitive screening and delirium monitoring

›Serial mental status checks

›Repeat attention testing

›Fluctuation documentation interval

›Every 30 to 60 minutes in unstable

›Every 2 to 4 hours in stable

14ECG/ecg16

Indications and high risk patterns

›ECG use in delirium

›Syncope or presyncope

›Chest pain

›Palpitations

›Electrolyte disturbance

›Antipsychotic or QT prolonging medication use

›High risk findings

›ST elevation

›New ST depression

›New T wave inversion

›Wide QRS

›QTc prolongation

›QTc >= 500 ms

›Avoid QT prolonging sedatives if possible

›High grade AV block

›Ventricular arrhythmia

15Assessment/ax18

Syndrome framing and severity

›Working diagnosis structure

›Delirium due to medical condition

›Hypoactive subtype risk for missed diagnosis

›Identify precipitant and vulnerability factors

›Primary psychiatric disorder as diagnosis of exclusion

›After medical and toxicologic causes addressed

›Severity and risk

›Hyperactive delirium with safety risk

›Hypoactive delirium with aspiration risk

›High risk etiologies under evaluation

›CNS infection

›Stroke

›Sepsis

Key support for diagnosis

›Supporting features

›Acute change from baseline

›Fluctuating course

›Inattention on bedside testing

›Disorganized thinking

16Plan/plan97

First 5 minutes

›Immediate stabilization

›Airway support if unable to protect airway

›Oxygen if hypoxic

›Target SpO2 92% to 96%

›Target SpO2 88% to 92% in chronic hypercapnia risk

›Cardiac monitor if unstable

›IV access criteria

›Hypotension

›Suspected sepsis

›Need for IV sedation

›Point of care glucose immediately

›Temperature measurement

›Deescalation environment

›Low stimulation

›Reorientation cues

Diagnostic sequencing

›Diagnostic priorities

›Reversible physiologic derangements first

›Hypoxia

›Hypoglycemia

›Hypercapnia

›Hypotension

›Infection evaluation by syndrome

›Urinary

›Pulmonary

›Skin

›Abdominal

›Neuro emergency evaluation when indicated

›Stroke pathway if focal findings

›CT head triggers present

›LP pathway if CNS infection concern

›Toxicologic evaluation when indicated

›Acetaminophen

›Salicylates

›Alcohol withdrawal risk assessment

Therapeutic plan

›Non pharmacologic measures

›Treat pain

›Ensure glasses and hearing aids

›Hydration correction

›Sleep promotion

›Avoid overnight disruptions when safe

›Agitation and dangerous behavior

›Initial approach

›Verbal de escalation

›One staff spokesperson

›Chemical sedation

›Haloperidol IV 0.5 mg

›Repeat 0.5 mg every 15 to 30 minutes to effect

›Typical total 1 mg to 5 mg

›Avoid in Parkinson disease

›Avoid in Lewy body dementia

›QTc monitoring

›Olanzapine IM 5 mg

›Repeat 5 mg after 2 hours if needed

›Maximum 10 mg in 24 hours in frail older adults local protocol dependent

›Avoid with benzodiazepines within 1 hour due to respiratory depression risk local protocol dependent

›Lorazepam IV 0.5 mg

›Preferred for alcohol withdrawal

›Repeat 0.5 mg to 1 mg every 10 to 20 minutes to effect

›Paradoxical disinhibition risk in older adults

›Ketamine IV 0.5 mg/kg

›Severe agitation with imminent harm

›Monitor for hypertension

›Monitor for hypersalivation

›Physical restraints

›Only as bridge to chemical sedation

›Continuous observation required

›Alcohol withdrawal treatment

›Thiamine IV 200 mg

›Give before glucose containing fluids when possible

›Repeat daily for 3 days if high risk

›Benzodiazepines

›Symptom triggered protocol local protocol dependent

›Escalation to ICU if refractory

Monitoring and reassessment

›Reassessment loop

›Vitals frequency

›Every 5 to 15 minutes during sedation

›Every 30 to 60 minutes when unstable

›Repeat mental status

›After each intervention

›After test results return

›Delirium contributors review

›New meds

›Urinary retention

›Constipation

›Pain

›Hypoxia

›Consultation triggers

›Neurology

›Suspected stroke

›Suspected nonconvulsive status epilepticus

›ICU

›Airway risk

›Refractory agitation

›Hypercapnia requiring ventilatory support

›Internal medicine or geriatrics

›Persistent delirium

›Frailty with unclear precipitant

17Disposition/dispo29

Level of care criteria

›ICU indications

›Need for ventilatory support

›Vasopressor requirement

›Status epilepticus

›Severe sepsis with shock

›Refractory agitation requiring continuous sedation

›Inpatient admission indications

›Persistent delirium without identified reversible cause in ED

›New serious diagnosis

›Pneumonia

›Sepsis

›Stroke

›CNS infection

›Unsafe discharge environment

›No reliable supervision

›High fall risk

›Need for IV therapy

›IV antibiotics

›IV fluids with monitoring

›Observation pathway

›Transient delirium with reversible cause treated

›Need for short interval reassessment after sedation

›Mild infection treated with stable vitals

›Discharge criteria

›Return to baseline cognition

›Vitals stable for 2 to 4 hours

›Reversible cause treated or ruled out with a plan

›Reliable caregiver present

›Clear follow up within 24 to 72 hours

18Discharge Instructions/di22

Copy discharge instructions

›Discharge instructions

›Today you were seen for confusion

›Your symptoms were consistent with delirium

›Delirium can come and go and is often caused by a medical problem

›Take your medications exactly as prescribed

›Do not drink alcohol

›Do not use recreational drugs

›Do not drive until you are back to normal and cleared if needed

›Drink fluids regularly unless you were told to restrict fluids

›Arrange supervision by a trusted adult for the next 24 hours

›Follow up with your family doctor within 1 to 3 days

›Return to the emergency department now for any of the following

›Fever

›Worsening confusion

›New weakness

›Trouble speaking

›Severe headache

›Seizure

›Fainting

›Chest pain

›Trouble breathing

›Inability to keep fluids down

19References/r7

Guidelines and tools

›Core references

›American Geriatrics Society clinical practice guideline for postoperative delirium in older adults, 2015

›NICE Delirium prevention diagnosis and management guideline, 2019 update

›Society of Critical Care Medicine PADIS guidelines for pain agitation delirium immobility and sleep disruption, 2018

›IDSA guidelines for bacterial meningitis management, 2004 with local protocol dependent updates

›AHA ASA acute ischemic stroke guidelines, 2019 update

›Confusion Assessment Method validation studies, original and subsequent validation cohorts

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.