12-phase flow (12)

1. 1FRAME
   IMMEDIATE: ABC + fingerstick glucose + thiamine if alcoholic + naloxone trial if pinpoint pupils; characterize AMS (sudden vs gradual, hypoactive vs hyperactive, GCS / FOUR) (Wijdicks NEJM 2008 PMID 18193394)
   inputs: fingerstick_glucose, ams_onset_time, ams_character
   advance: reversible causes (hypoglycemia, opioid, hypoxia) excluded or treated; GCS documented
2. 2ENTRY
   Focal neuro deficit, seizure activity, headache, chest pain/dyspnea, recent med changes, recent falls/trauma → narrow toward vascular / seizure / infection / tox / structural
   inputs: associated_focal_deficit, associated_seizure_activity, associated_headache, recent_medication_changes, recent_falls_or_trauma
   advance: entry presentation captured
3. 3CONTEXT
   Age, sex, baseline cognition, DM, liver, CKD, thyroid, alcohol, anticoag, recent infection, immunocompromise, psych — comorbidity-anchored differential narrowing (Inouye 2014)
   inputs: age, sex, baseline_cognition, sbp, hr, rr, temp, spo2, diabetes_mellitus, liver_disease_cirrhosis, ckd_or_dialysis, thyroid_disease, alcohol_use_disorder, anticoagulant_use, recent_infection
   advance: context complete
4. 4RED_FLAGS
   Hypoglycemia (D50W stat); hypoxia (O2/intubation); hypercapnia (BiPAP); opioid (naloxone); status epilepticus (benzo + AED); meningitis (abx within 1 h); stroke / ICH / SAH (STAT CT + thrombolytic/reversal pathway); DKA/HHS; thyroid storm / myxedema coma; adrenal crisis; sepsis bundle (SSC 2026)
   inputs: fingerstick_glucose, spo2, sbp, temp
   advance: no immediate life-threat OR appropriate engine activated
5. 5INITIAL_WORKUP
   CBC + diff, BMP with anion gap, LFT with ammonia, TSH + free T4, serum osmolality, lactate, UA, acetaminophen + salicylate levels (universal), ethanol level, ABG with CO-Hb, blood cultures x2, ECG (Inouye 2014; Wijdicks 2008)
   inputs: cbc_with_diff, bmp_with_anion_gap, lft_with_ammonia, tsh_free_t4, serum_osmolality_and_calculated_gap, lactate, urinalysis_and_drug_screen, acetaminophen_salicylate_levels, ethanol_level, abg_with_co_hb, blood_cultures_x2, ecg_12_lead
   actions: panel.cbc, panel.renal, panel.lft, panel.inflammation
   advance: initial workup reviewed + phenotype pivoted
6. 6BRANCHING_WORKUP
   STAT non-contrast head CT (focal deficit / new seizure / anticoag-trauma / suspected ICH/SAH); MRI DWI for posterior stroke / HSV encephalitis / PRES; LP after CT (meningitis / encephalitis / SAH xanthochromia); continuous EEG for nonconvulsive status (Brophy 2012)
   inputs: noncon_head_ct, mri_brain_for_ischemia, lumbar_puncture, eeg_for_nonconvulsive_status
   advance: branching workup pivots to disposition route
7. 7DIFFERENTIAL
   AEIOU-TIPS / VITAMINS-D frame — pre-test priors at ED adult AMS population: delirium (>65) ~30%, sepsis-encephalopathy ~15%, metabolic (hypo/hyper-Na, hypoglyc, uremic, hepatic) ~20%, intoxication ~10%, stroke/ICH/SAH ~5-10%, seizure / postictal ~5%, meningitis/encephalitis ~2-5%, endocrine (DKA/HHS/thyroid/adrenal) ~5%, Wernicke/B12 deficiency ~1-2%, structural (mass, NPH, subdural) ~3-5%, psychiatric ~3-5%
   advance: differential ranked with pre-test priors documented
8. 8RISK_STRATIFICATION
   GCS / FOUR score for coma depth + intubation threshold (GCS ≤8 → intubate); CAM for delirium screening (Inouye 2014); RASS for sedation; SOFA/qSOFA for sepsis (SSC 2026); West Haven grade for hepatic encephalopathy; APACHE II in ICU — all schema-blocked in clinical-tools-registry
   inputs: age
   advance: risk scores documented
9. 9TREATMENT
   Universal AMS bundle: D50W 50 mL IV if glucose <70; thiamine 500 mg IV BEFORE glucose in alcoholics (Wernicke prevention PMID 32553711); naloxone 0.4-2 mg IV if opioid suspicion; O2 to SpO2 ≥94; protect airway if GCS ≤8 (intubate); treat the cause (route to dedicated engine). AVOID empiric flumazenil (seizure risk). Empiric ceftriaxone + vancomycin + ampicillin + dexamethasone for meningitis suspicion (within 1 h). Empiric acyclovir 10 mg/kg q8h for HSV encephalitis suspicion (temporal MRI / CSF lymphocytic pleocytosis). Empiric hydrocortisone 100 mg IV if adrenal crisis suspicion. tPA / thrombectomy pathway for ischemic stroke (Powers AHA 2019 → neuro.ischaemic-stroke.v1).
   inputs: fingerstick_glucose, spo2, sbp
   advance: universal bundle initiated + cause-specific Rx routed
10. 10DISPOSITION
    Reversed metabolic AMS (hypoglycemia fully treated, normalized hyponatremia) + reliable home + close PCP follow-up → discharge with return precautions; sepsis-encephalopathy → admit / ICU per SSC 2026; stroke / ICH / SAH → neuro ICU; status epilepticus → neuro ICU; thyroid storm / myxedema coma / DKA / HHS / adrenal crisis → ICU; meningitis/encephalitis → admit; severe delirium with safety concerns → admit with sitter; tox phenotypes → ICU or psych admit per agent
    advance: disposition assigned + downstream handoff complete
11. 11MONITORING
    Serial GCS / FOUR; vital signs q15 min × 1 h then q30 min × 4 h; continuous SpO2 + telemetry; serial glucose q1-2h if hypoglycemia treated; Na correction rate ≤8 mEq/L/24 h (osmotic demyelination risk); reassess CAM q shift for delirium; serial Cr / lactate for resuscitation adequacy
    inputs: fingerstick_glucose, lactate
    advance: stability achieved or escalation triggered
12. 12FOLLOWUP
    Discharged: PCP within 48-72 h; medication reconciliation (deprescribe offending agents); cognitive screen at outpatient visit; behavioral interventions for delirium prevention (sleep, mobilization, hydration, family at bedside, sensory aids); referral to neurology / psych / endocrine / hepatology as indicated
    advance: discharge bundle prescribed + follow-up scheduled