Emergency Medicine

ALTERED CONSCIOUS LEVEL

General Medical Emergencies 81

The following categories are covered, although they may overlap:
● Confused patient
● Alcohol-related medical problems
● Patient with an altered conscious level and smelling of alcohol
● Alcohol withdrawal.
The collapsed or unconscious patient in coma is covered separately in Section I
on p. 24.

Confused patient

‘C o n f u s i o n’ o r d e l i r iu m i s a t r a n s i e nt g l o b a l d i s o rd e r o f c o g n i t i o n. It i s a s y n d r o m e
(not a diagnosis) with multiple causes that describes a state of clouding of
consciousness or disturbed awareness, which may f luctuate.

DIAGNOSIS

1 An acute confusional state may go unrecognized or be mistaken for demen-
tia or depression particularly in the elderly (see p. 119), or for mania and even
acute schizophrenia.

2 There is usually abrupt onset of:
(i) Clouding of consciousness that may fluctuate, disorientation
in time and place, impaired memory, visual, olfactory or tactile
hallucinations and illusions.
(ii) Difficulty maintaining attention, restlessness, irritability,
emotional lability and poor comprehension.
(iii) Hyperactive state with increased arousal and reversed sleep-wake
cycle, or hypoactive and withdrawn.

3 Causes of confusion.
(i) Hypoxia
(a) chest infection, COPD, pulmonary embolus, cardiac failure
(b) respiratory depression from drugs, or weakness, e.g.
Guillain–Barré syndrome, myasthenia gravis or muscular
dystrophy
(c) chest injury or head injury
(d) drowning, smoke inhalation.
(ii) Drugs
(a) intoxication or withdrawal from alcohol, sedatives, cocaine,
amphetamines, phencyclidine
(b) side effects (especially in the elderly and with polypharmacy)
of analgesics, anticonvulsants, psychotropics, digoxin,
anticholinergics and antiparkinsonian drugs such as
benzhexol (trihexyphenidyl) and levodopa
(c) inappropriate use, such as steroids particularly anabolic.
(iii) Cerebral
(a) meningitis, encephalitis
(b) head injury