Toxic delirium

DSM-V criteria

• Disturbance in attention and awareness
• Change in cognition that is not better accounted for by pre-existing, established or evolving dementia
• Disturbance develops over hours to days and fluctuates
• Evidence that disturbance is caused by direct a direct physiological consequence of a general medical condition, intoxicant or more than one cause

Resuscitation

• ABC
• Consider atypical or non-consulsive status as cause early and treat with benzos if suspected
• Check BSL early
• Check temperature and continously monitor if >38.5

Risk assessment

• Must vigorously assess for:
  • Possible causes (toxicological)
  • Important complications
  • Alternative non-toxicological causes
  • Specific toxidromes that require specific interventions

Risk assessment

• Toxicological differential
  • Alcohol
  • Anticholinergic delirium
  • Antidepressants (Bupropion, MAOi, venlafaxine)
  • Atypical antipsychotics
  • Baclofen
  • Benzo’s/zolpidem/zopiclone
  • Cannabis
  • Hallucinogenic agents
  • Neuroleptic malignant syndrome
  • Nicotine
  • Salicylates
  • Sympathomimetic syndrome
  • Theophylline
  • Withdrawal of benzo/alcohol/opioid

Risk assessment

• Complications
  • Aspiration pneumonitis
  • DVT/PE
  • Fluid, electrolyte and acid-base disturbance
  • Hypoventilation/hypoxia
  • Hyperthermia
  • Physical injury
  • Rhabdomyolysis

Risk assessment

• Mimics
  • Acid-base disturbance
  • Behavioural
  • CNS infection
  • Dementia
  • Electrolyte disturbance e.g. hyponatraemia
  • Endocrine emergency e.g. thyroid storm
  • Head injury
  • Hypoglycaemia
  • Hypoxia
  • Organ failure e.g. hepatic encephalopathy
  • Psychosis
  • Seizures (NCSE)
  • Stroke (INCL. POSTERIOR)
  • Trauma e.g. subdural heamorrhage)
  • Withdrawal

Risk assessment

• Agents that may require specific intervention
  • Anticholinergics – Physostigmine
  • Neuroleptic malignant syndrome – Bromocriptine
  • Salicylates – Urinary alkalinisation +- dialysis
  • Serotonin syndrome – Cyproheptadine, paralysis I&V
  • Theophylline – MDAC +- haemodialysis

General supportive cares

• Monitoring of airway and conscious state
• Respiratory toilet and prophylaxis e.g. mobilisation/chest physio
• Fluid monitoring
• Bladder care
• Prevention of pressure areas
• DVT prophylaxis
• Mobilisation as mental status changes

Last Updated on October 13, 2020 by Andrew Crofton