CURRENT Essentials of Critical Care.pdf

Chapter 13 Neurology 189Altered Mental Status in the ICU■ Essentials of Diagnosis• Agitation, delirium, decreased sensorium, or waxing and waningof consciousness• Disorganized thinking with rambling, incoherent speech, shouting,moaning• Hallucinations or illusions; appear fearful, restless• Disorientation to time, place, situation• Serial examinations imperative as symptoms may fluctuate• Agitated patients can demonstrate hypertension, tachycardia,tachypnea, increased oxygen needs, ventilatory difficulties• Difficult to assess pharmacologically sedated patients• Mini Mental Status Examination (MMSE), Cognitive Test forDelirium (CTD), Confusion Assessment Method for the IntensiveCare Unit (CAM-ICU) may be helpful• Dementia and delirium may be differentiated by EEG findings• Delirium in ICU associated with increased mortality, length ofstay, need for subsequent nursing home placement■ Differential Diagnosis• Hypoxemia, hypoperfusion• Hypoglycemia, electrolyte abnormalities• Thyrotoxicosis• Postoperative states• Sleep deprivation, head trauma• Postictal states• Medications, withdrawal or intoxication• Infection: systemic, CNS, HIV■ Treatment• Identify causes, withdraw potential offending drugs, treat underlyingetiology• Symptomatic treatment if patient is danger to self or others• Enlist assistance from family to aid in orientation to self, location,time (day/night), situation• If unexplained, consider trial of benzodiazepines to exclude alcoholor benzodiazepine withdrawal; haloperidol with or withouta benzodiazepine; or atypical antipsychotic■ PearlInstructing patients to report strange phenomenon, empathetically informingthem you understand their sense of confusion, and reassuringfamily members are important aspects of the social and psychologicmanagement of ICU patients.ReferenceCohen IL et al: Management of the agitated intensive care unit patient. CritCare Med 2003;30:S97. [PMID: 11852874]