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Altered Mental Status

Glucose first — then work the list that kills.

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Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

  1. Glucose and oxygen before the mnemonic.
  2. Treat reversible causes while you work AEIOU-TIPS.
  3. Give thiamine with dextrose — never delay glucose.

2 · Escalate now if

  • Falling GCS or new focal neurology
  • Hypoglycemia or hypothermia
  • Meningismus, fever, or new seizure
  • Suspected overdose with QRS widening or absent gag reflex
  • Anticoagulation + head injury
  • Hypercapnia or acidosis on VBG

3 · Immediate workup

  • Glucose, SpO₂, temperature, VBG
  • ECG (TCA patterns, ischemia, dysrhythmia)
  • POCUS for free fluid / obvious cranial findings as trained

4 · Don’t miss

  • Hypoglycemia / hyperglycemic crises
    Bedside glucose in every AMS patient — before anything else. Never delay dextrose for thiamine.
  • Hypoxia / hypercapnia
    SpO₂, VBG; think CO₂ narcosis in COPD.
  • Stroke / intracranial hemorrhage
    Sudden onset, focal signs, anticoagulation — non-contrast CT now. IV tenecteplase or alteplase if eligible within 4.5 h; mechanical thrombectomy up to 24 h in selected patients, including some large-core and basilar occlusions (2026 AHA/ASA) — not a rigid 6-hour wall.
  • SAH
    Sudden headache + collapse; CT then LP or CTA as indicated.
  • Meningitis / encephalitis
    Fever, meningismus — empiric therapy must not wait on imaging.

5 · Disposition lane

Admit

Delirium of unclear cause, treated infection under observation, uncorrected metabolic derangement.

ICU / stroke pathway

Coma, airway compromise, status epilepticus, severe intoxication, massive ICH, fulminant sepsis, large-vessel occlusion within the EVT window.