What is the immediate management for a patient with altered sensorium?

Immediate Management of Altered Sensorium

Secure the airway immediately if the Glasgow Coma Scale is ≤8 or the patient cannot protect their airway, obtain fingerstick glucose at bedside within the first minute, and simultaneously initiate vital sign assessment while preparing for targeted laboratory workup and neuroimaging based on clinical risk factors. 1

Airway and Breathing Assessment

• Intubate immediately if GCS ≤8 or if the patient shows inability to protect the airway, as this represents the highest priority intervention to prevent aspiration and hypoxic brain injury 1
• Assess respiratory pattern and oxygen saturation, as abnormal breathing patterns may indicate brainstem dysfunction or metabolic derangement 1

Immediate Bedside Interventions

• Check fingerstick glucose immediately before any other intervention, as hypoglycemia is rapidly reversible and can cause permanent neurological damage if untreated 1
• Administer thiamine 500mg IV before giving glucose in any patient with malnutrition, alcoholism, or risk factors for deficiency to prevent precipitating Wernicke encephalopathy 1
• If hypoglycemia is confirmed, give IV dextrose immediately after thiamine 1
• Administer naloxone if opioid toxicity is suspected based on pinpoint pupils, respiratory depression, or known substance use history 1

Vital Signs and Objective Mental Status Quantification

• Document temperature, blood pressure (including orthostatic changes if safe), heart rate, and respiratory rate systematically, as fever suggests infection, hypotension suggests shock or sepsis, and hypertension may indicate intracranial pathology 1
• Quantify mental status using Glasgow Coma Scale or FOUR score rather than subjective descriptors like "lethargic" or "confused" 1
• Perform focused neurological examination specifically looking for focal deficits (asymmetric weakness, gaze deviation, pupillary asymmetry, cranial nerve palsies), as these findings substantially increase likelihood of structural brain lesion requiring urgent imaging 1

Critical History Elements (Obtain Simultaneously)

• Temporal profile: abrupt onset suggests stroke or toxin; subacute suggests infection or metabolic cause 1
• Complete medication list including over-the-counter drugs, recent antibiotics (which may predispose to Clostridioides difficile or alter mental status directly), alcohol, and illicit substances 1
• Infectious symptoms: fever, headache, neck stiffness, recent infections, immunocompromised state 2, 1
• Recent trauma or falls, especially in elderly or anticoagulated patients 1
• Comorbid conditions: diabetes, renal failure, liver disease, HIV/AIDS, malignancy 2, 1

Initial Laboratory Workup (Order Immediately and Simultaneously)

• Point-of-care glucose (if not already done) 1
• Complete metabolic panel to assess sodium, potassium, calcium, renal function, and glucose 1
• Complete blood count to evaluate for infection, anemia 1
• Liver function tests 1
• Urinalysis 1
• Toxicology screen and acetaminophen level when substance use is suspected or history is unclear 1
• Arterial or venous blood gas if metabolic acidosis is suspected 3

Neuroimaging Decision Algorithm

Obtain non-contrast head CT immediately if ANY of the following are present: 1

• Focal neurological deficits on examination
• History of head trauma or falls
• Current anticoagulation use
• Age >60 with unexplained altered mental status
• New-onset seizure
• Papilledema or signs of increased intracranial pressure

Consider MRI brain if CT is negative but high clinical suspicion exists for encephalitis, posterior circulation stroke, or inflammatory/autoimmune conditions 1

Lumbar Puncture Considerations

• Perform lumbar puncture when CNS infection is suspected (fever, headache, neck stiffness, immunocompromised state) but only after neuroimaging rules out mass effect or increased intracranial pressure 1
• Send cerebrospinal fluid for cell count with differential, protein, glucose, Gram stain, bacterial culture, and consider viral PCR panel if encephalitis is suspected 1
• In infectious diarrhea patients with altered sensorium, this may represent severe dehydration or systemic infection requiring aggressive fluid resuscitation 2

Empiric Treatment While Awaiting Results

• Start empiric antibiotics and acyclovir immediately if meningitis or encephalitis cannot be excluded, even before lumbar puncture if there will be any delay in performing it 1
• For suspected bacterial meningitis: vancomycin plus third-generation cephalosporin (ceftriaxone or cefotaxime); add ampicillin if age >50 or immunocompromised 1
• Add acyclovir 10mg/kg IV every 8 hours for possible herpes simplex encephalitis 1
• Correct severe electrolyte abnormalities cautiously (hyponatremia, hypernatremia, hypoglycemia, hypercalcemia) as both the abnormality and overly rapid correction can worsen mental status 3

Critical Pitfalls to Avoid

• Never attribute altered sensorium to psychiatric causes without completing full medical workup, as organic causes are far more common and missing them can be fatal 1
• Consider multiple concurrent etiologies, especially in elderly patients who may have baseline dementia plus acute infection plus medication effect 1
• Do not assume a single positive finding (like positive malaria smear) explains everything if symptoms persist or focal findings develop; CNS tuberculosis can coexist with other infections 4
• Recognize that 20-25% of altered sensorium cases are toxicologic/pharmacologic, making medication reconciliation essential 1
• In patients with infective endocarditis presenting with altered sensorium, consider intracranial mycotic aneurysm, which has 60% mortality and may present with headache, altered sensorium, or focal deficits before catastrophic rupture 2

Specific High-Risk Scenarios

• Diabetic ketoacidosis with hypernatremia: use initial isotonic saline bolus followed by half-normal saline to correct hypernatremia while treating DKA, as standard DKA protocols may worsen hypernatremia 3
• Infective endocarditis with neurological symptoms: obtain urgent neuroimaging as intracranial mycotic aneurysms occur in 1.2-5% of cases with 80% mortality if ruptured 2
• Refractory seizures with hyponatremia: consider autoimmune encephalitis (anti-LGI1 antibody) if seizures persist despite antiepileptics and recurrent electrolyte abnormalities are present 5