›Repeat every 2 to 3 minutes to RR and airway protection
›If no IV, intranasal 2 mg to 4 mg
›Flumazenil avoidance
›Contraindicated in chronic benzodiazepine use
›Contraindicated in mixed overdose with seizure risk
Seizure management
›Seizure treatment pathway
›Benzodiazepine first line
›Lorazepam 2 mg IV
›Repeat once after 5 minutes if ongoing
›Second line antiseizure
›Levetiracetam 60 mg/kg IV maximum 4500 mg
›Valproate IV local protocol dependent
›Refractory seizure
›Airway control
›Continuous infusion local protocol dependent
Shock and sepsis
›Shock management
›Broad spectrum antibiotics within 1 hour if septic shock concern local protocol dependent
›Lactate guided resuscitation
›Source control planning
Diagnostic sequencing
›Diagnostic sequence
›Glucose first
›ECG early
›VBG and electrolytes early
›CT head early if focal findings or trauma risk
Reassessment loop
›Reassessment loop
›Neuro checks every 15 minutes until stable
›Vitals every 5 minutes if unstable
›Repeat glucose every 30 to 60 minutes if hypoglycemia risk
›Repeat VBG and lactate within 2 hours if shock concern
17Disposition/dispo20
ICU criteria
›ICU indications
›Mechanical ventilation
›Vasopressor requirement
›Refractory seizures
›Persistent GCS <= 8 after initial stabilization
Inpatient admission criteria
›Inpatient admission
›Persistent altered mental status of unclear cause
›Intracranial pathology on imaging
›Sepsis or CNS infection concern
›High risk overdose requiring monitoring
Observation pathway
›Observation candidates
›Reversed hypoglycemia with identified cause and stable monitoring plan
›Alcohol intoxication with improving mental status and safe supervision
›Single brief seizure with full recovery and established diagnosis
Discharge criteria
›Discharge criteria
›Return to baseline mental status
›Normal vital signs
›Cause identified and treated
›No high risk co ingestion or delayed toxicity concern
›Reliable supervision and follow up
18Discharge Instructions/di7
Copy discharge instructions
›Discharge instructions
›Today you were seen for an episode of unresponsiveness that improved after treatment and observation.
›Avoid driving, swimming, heights, and operating machinery until cleared by a clinician.
›Do not mix alcohol with sedating medications.
›Take medications exactly as prescribed and do not take extra doses.
›Return to the emergency department immediately for trouble breathing, chest pain, repeated vomiting, severe headache, new weakness, another episode of unresponsiveness, or any seizure.
›Follow up with your primary care clinician within 1 to 3 days, and with neurology or cardiology if recommended.
19References/r6
Guidelines and key sources
›Core references
›American College of Emergency Physicians clinical policies on altered mental status and related presentations local protocol dependent
›Neurocritical Care Society status epilepticus guidelines latest version local protocol dependent
›American Heart Association ACLS guidelines most recent update local protocol dependent
›American Academy of Clinical Toxicology position statements on toxic alcohols local protocol dependent
›American Diabetes Association guidance on hypoglycemia recognition and treatment latest version local protocol dependent
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.