Adult Medical Emergency Handbook - Scottish Intensive Care Society

• Urinalysis +/- MSU
• CXR
• ECG
• Abdo USS if LFTs deranged – eg. to investigate possible cholecystitis
• Consider CT brain +/- LP if delirium persists without known precipitant.
Further investigations should be under the supervision of a specialist.
MANAGEMENT
• Because delirium is usually due to an interaction between multiple
predisposing factors and precipitating factors, management
should be aimed at not just finding and treating the assumed
cause, but also optimising all aspects of care:
1. optimise physiology: correct hypoxia and hypoglycemia, treat
anaemia, dehydration, hyponatraemia, malnourishment, etc.
2. treat any possible precipitants
3. stop or reduce deliriumogenic drugs (amitriptyline, etc.) –
consult pharmacist if unsure
4. minimise mental stress – provide repeated re-orientation,
involve family/carers, and provide care in as quiet and stable
an environment as possible (eg. side room)
5. avoid prolonged bedrest: mobilisation can help recovery
• Management is best carried out on specialist units: transfer to
Acute Medicine of the Elderly ward early. Appropriate nursing care
can often avoid sedation (quiet, well lit environment).
• If agitation causes severe distress or immediate danger of injury
consider using drug treatment. The first line drug is haloperidol
0.5mg oral or im, at intervals of 20 min – 1 hr until agitation is reduced
to acceptable levels. If in any doubt contact a senior colleague for
advice or seek specialist help. See below for further details
ADDITIONAL POINTS
• Benzodiazepines prolong delirium and may worsen outcome. Do
not use unless under specialist supervision, alcohol withdrawal
is suspected, or the patient has Parkinson’s disease or dementia
with Lewy Bodies.
• Delirium is very common in dying patients – treat cause(s) if
possible and consider antipsychotics
• Differentiation between depression, dementia and delirium can be
difficult, and where the delirium persists seek specialist advice.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11
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