symptom.altered_mental_status.ed.v1PRODUCTION

symptom.altered_mental_status.ed.v1

Altered mental status (ED workup — undifferentiated AMS)

symptomacuteundifferentiatedadult

Hard-required inputs

0 / 32

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

Actions

Advance rule

Set

Advance when

reversible causes (hypoglycemia, opioid, hypoxia) excluded or treated; GCS documented

Severity triggers (18)

18 need judgement

informationallife_threateninghypoglycemia
Fingerstick glucose <70 mg/dL with AMS — D50W 50 mL IV stat; thiamine BEFORE glucose in alcoholics (PMID 32553711)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningopioid_toxicity
Pinpoint pupils + bradypnea + AMS — naloxone 0.4-2 mg IV/IM/IN; titrate to RR; consider infusion for long-acting opioids (methadone, fentanyl analogs)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningischemic_stroke
Sudden focal deficit + AMS + LKW <24 h → STAT non-contrast head CT + CTA + tPA/thrombectomy pathway (Powers AHA 2019)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningintracerebral_hemorrhage
Sudden focal deficit + AMS + acute hypertension + anticoag → STAT non-contrast head CT shows ICH; BP control + reversal of anticoag + neurosurgery (AHA 2022)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningsubarachnoid_hemorrhage
Thunderclap headache + AMS ± focal deficit + meningismus → STAT non-contrast head CT (sensitivity >95% at 6 h); LP for xanthochromia if CT negative; CTA for aneurysm
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningstatus_epilepticus_or_post_ictal
Active convulsion >5 min OR ≥2 seizures without recovery between → status epilepticus; postictal AMS resolving within 30-60 min may need EEG for nonconvulsive status (Brophy NCS 2012)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningbacterial_meningitis_or_encephalitis
Fever + AMS + meningismus / petechiae OR temporal-lobe MRI / CSF lymphocytic pleocytosis → empiric ceftriaxone + vancomycin + ampicillin + dexamethasone (bacterial) OR acyclovir (HSV) within 1 h (Tunkel IDSA PMID 22119250)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningsevere_hyponatremia
Na <120 mEq/L + AMS / seizure — 3% saline 100 mL bolus q10 min x 3 (max ΔNa 6-8 mEq/L per 24 h to avoid osmotic demyelination) (syndrome.hyponatremia.core.v1)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningsevere_hyperkalemia
K >6.5 mEq/L + ECG changes (peaked T, widened QRS, sine wave) + AMS — calcium gluconate + insulin/dextrose + albuterol + Kayexalate/patiromer + dialysis if refractory (syndrome.hyperkalemia.core.v1)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningthyroid_storm_or_myxedema_coma
Thyroid storm (Burch-Wartofsky ≥45 — fever + tachy + AMS + GI + thyrotoxic) → PTU + propranolol + hydrocortisone + iodine; myxedema coma (hypothermia + bradycardia + hyponatremia + AMS + hypothyroid) → levothyroxine + hydrocortisone + passive rewarming (endo.thyroid-storm.core.v1 / endo.myxedema-coma.core.v1)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverehypoxia_or_hypercapnia
SpO2 <90% (hypoxic encephalopathy) OR pCO2 >50 on ABG (CO2 narcosis from COPD/OSA) — O2 + BiPAP / intubation per phenotype
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresepsis_encephalopathy
Infection source (pneumonia / UTI / skin / abdominal / meningitis) + qSOFA ≥2 OR lactate >2 OR SBP <100 + AMS → sepsis-encephalopathy (SSC 2026)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresevere_hypernatremia
Na >160 mEq/L + AMS — controlled correction with hypotonic fluids; max ΔNa 10-12 mEq/L per 24 h (cerebral edema risk if too fast)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverehepatic_encephalopathy
Known cirrhosis + AMS + asterixis + elevated ammonia → West Haven grade III/IV; lactulose + rifaximin + treat precipitant (GI bleed, SBP, dehydration, sedatives) (AASLD 2014)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveredka_or_hhs
Hyperglycemia + AMS + (DKA: anion gap acidosis + ketones; HHS: osm >320, profound hyperglycemia >600, minimal ketones) → insulin infusion + IVF + K replacement (endo.dka.core.v1 / endo.hhs.core.v1)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveretoxic_overdose
Acetaminophen / salicylate / toxic alcohols / CO / sympathomimetic / sedative-hypnotic / TCA / Na-channel blocker — universal acetaminophen + salicylate level + ethanol + UDS + osmolar gap + ABG with CO-Hb
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverewernicke_or_korsakoff
Alcohol use disorder or malnutrition + AMS / ataxia / ophthalmoplegia → Wernicke triad; thiamine 500 mg IV q8h x 2 days BEFORE glucose (PMID 32553711)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatedelirium
Acute fluctuating AMS + inattention + disorganized thinking OR altered LOC (CAM positive) — usually multifactorial in elderly (infection, meds, dehydration, sleep, pain, urinary retention, fecal impaction) (Inouye NEJM 2014 PMID 22504182)
Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ed playbook — drug actions (12)

1. thiamine
500 mg IV (or 100 mg IV if not alcoholic/malnourished) • IV • q8h x 2 days then 100 mg IV/PO daily
trigger: ANY suspected alcohol use disorder OR malnutrition OR hyperemesis OR before D50W in adult AMS
Wernicke encephalopathy prevention — thiamine BEFORE glucose in alcoholics (glucose load without thiamine precipitates Wernicke); Wernicke-Korsakoff Guidelines PMID 32553711
2. dextrose 50% (D50W)
rxcui 4850
50 mL (25 g) IV push • IV • once, repeat q5 min until glucose >70
trigger: Fingerstick glucose <70 mg/dL with AMS
Rapidly reversible cause of AMS; if no IV access use glucagon 1 mg IM; recheck glucose in 15 min
3. naloxone
rxcui 7242
0.4-2 mg IV/IM/IN; titrate to respiratory rate >10 • IV/IM/IN • repeat q2-3 min PRN; consider infusion if long-acting opioid
trigger: Suspected opioid intoxication (pinpoint pupils + bradypnea + AMS)
Reverses opioid-induced respiratory depression; short half-life requires repeat dosing or infusion for long-acting agents (methadone, fentanyl analogs)
4. oxygen
2-15 L/min via NC or NRB; titrate to SpO2 ≥94% • inhaled • continuous
trigger: SpO2 <94% OR hypoxic encephalopathy OR CO poisoning suspicion (100% NRB regardless of SpO2)
CO has 240x affinity for Hb vs O2; 100% O2 halves CO-Hb half-life from 5 h to 1 h; hyperbaric for severe (CO-Hb >25% or pregnant or LOC) → tox.co-poisoning.core.v1
5. ceftriaxone + vancomycin + ampicillin + dexamethasone
Ceftriaxone 2 g IV q12h; vancomycin 15-20 mg/kg IV (loading); ampicillin 2 g IV q4h (age >50 / immunocomp / pregnant); dexamethasone 10 mg IV q6h x 4 days • IV • per agent above
trigger: Suspected bacterial meningitis (fever + AMS + meningismus / petechiae / age >50 risk); start WITHIN 1 H
IDSA bacterial meningitis (Tunkel PMID 22119250 — verify) — empiric coverage + dexamethasone BEFORE first abx dose; route to id.bacterial-meningitis.core.v1
6. acyclovir
10 mg/kg IV q8h (renal adjust) • IV • q8h x 14-21 days
trigger: Suspected HSV encephalitis (fever + AMS + temporal-lobe MRI findings OR CSF lymphocytic pleocytosis with negative bacterial workup); empiric while HSV PCR pending
HSV encephalitis has 70% mortality untreated; empiric acyclovir while awaiting CSF HSV PCR; no dedicated dossier — consult-based / general ID workflow
7. lorazepam (status epilepticus first-line)
rxcui 6470
4 mg IV (or 2 mg if elderly/small); may repeat in 5-10 min • IV • once then repeat once
trigger: Active convulsive seizure OR nonconvulsive status on EEG
Brophy NCS 2012 — benzodiazepine first-line for status; then load AED (levetiracetam 60 mg/kg or fosphenytoin 20 PE/kg) → neuro.status-epilepticus.core.v1
8. hydrocortisone (adrenal crisis)
100 mg IV bolus then 50 mg IV q6h or 200 mg/24 h infusion • IV • bolus + q6h
trigger: Suspected adrenal crisis (known adrenal insufficiency or steroid-dependent + AMS + hypotension + hyperK + hypoNa)
Empiric stress-dose steroids before cortisol/ACTH results; route to endo.adrenal-crisis.core.v1
9. levothyroxine + hydrocortisone (myxedema coma)
Levothyroxine 200-400 mcg IV bolus then 50-100 mcg IV daily; hydrocortisone 100 mg IV q8h until adrenal axis confirmed • IV • bolus + maintenance
trigger: Suspected myxedema coma (hypothermia + bradycardia + hyponatremia + AMS + known/likely hypothyroidism)
Myxedema coma has 30-50% mortality; thyroid hormone + steroid + passive rewarming + supportive care → endo.myxedema-coma.core.v1
10. propylthiouracil or methimazole + propranolol + hydrocortisone (thyroid storm)
PTU 600-1000 mg PO load then 200-300 mg q4h; OR methimazole 60-80 mg PO then 30 mg q6h; propranolol 60-80 mg PO q4h; hydrocortisone 100 mg IV q8h; iodine 1 h after PTU • PO + IV • per agent
trigger: Suspected thyroid storm (Burch-Wartofsky ≥45 or fever + tachycardia + AMS + GI distress + known thyrotoxicosis)
Thyroid storm has 10-30% mortality; PTU/methimazole + beta-blocker + steroid + iodine + supportive → endo.thyroid-storm.core.v1
11. lactulose + rifaximin (hepatic encephalopathy)
Lactulose 30 mL PO/PR q1-2h initially then titrate to 2-3 soft stools/day; rifaximin 550 mg PO BID • PO/PR • titrate
trigger: Cirrhotic + AMS + asterixis + elevated ammonia → hepatic encephalopathy West Haven grade III/IV
AASLD 2014 HE — lactulose first-line; rifaximin add-on; treat precipitant (GI bleed, SBP, constipation, dehydration, sedatives) → gi.hepatic-encephalopathy.core.v1
12. N-acetylcysteine (acetaminophen overdose)
IV: 150 mg/kg over 1 h, then 50 mg/kg over 4 h, then 100 mg/kg over 16 h (Rumack-Matthew nomogram positive at 4 h post-ingestion) • IV • per protocol
trigger: Acetaminophen level above Rumack-Matthew treatment line OR concerning unknown ingestion timing
NAC near-100% hepatoprotective if started within 8 h; still beneficial >24 h post-ingestion in hepatotoxicity → tox.acetaminophen-overdose.core.v1

Auto-drafted A&P note

Subjective

- Possible entry pathways: Acute confusion / disorientation — delirium screen + medical workup (Inouye NEJM 2014 PMID 22504182); Decreased level of consciousness / coma — GCS / FOUR score; immediate ABC + glucose + naloxone trial (Wijdicks NEJM 2008 PMID 18193394); Acute agitation / hyperactive delirium / psychosis — rule out medical cause before psychiatric (Inouye 2014).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Altered mental status (ED workup — undifferentiated AMS)** (symptom.altered_mental_status.ed.v1).
Phenotype framing: 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%
Scope: 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)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Universal AMS bundle (glucose / thiamine / naloxone / O2 / airway); rule out life-threats (hypoglycemia / hypoxia / opioid / status epilepticus / meningitis / stroke / ICH / SAH / DKA / HHS / thyroid storm / myxedema coma / adrenal crisis / sepsis / Wernicke); risk-stratify with GCS / FOUR / CAM / qSOFA; route confirmed phenotype to dedicated engine (Wijdicks 2008 PMID 18193394; Inouye 2014 PMID 22504182; Wernicke-Korsakoff PMID 32553711)
1. thiamine 500 mg IV (or 100 mg IV if not alcoholic/malnourished) IV q8h x 2 days then 100 mg IV/PO daily — ANY suspected alcohol use disorder OR malnutrition OR hyperemesis OR before D50W in adult AMS (Wernicke encephalopathy prevention — thiamine BEFORE glucose in alcoholics (glucose load without thiamine precipitates Wernicke); Wernicke-Korsakoff Guidelines PMID 32553711)
2. dextrose 50% (D50W) 50 mL (25 g) IV push IV once, repeat q5 min until glucose >70 — Fingerstick glucose <70 mg/dL with AMS (Rapidly reversible cause of AMS; if no IV access use glucagon 1 mg IM; recheck glucose in 15 min)
3. naloxone 0.4-2 mg IV/IM/IN; titrate to respiratory rate >10 IV/IM/IN repeat q2-3 min PRN; consider infusion if long-acting opioid — Suspected opioid intoxication (pinpoint pupils + bradypnea + AMS) (Reverses opioid-induced respiratory depression; short half-life requires repeat dosing or infusion for long-acting agents (methadone, fentanyl analogs))
4. oxygen 2-15 L/min via NC or NRB; titrate to SpO2 ≥94% inhaled continuous — SpO2 <94% OR hypoxic encephalopathy OR CO poisoning suspicion (100% NRB regardless of SpO2) (CO has 240x affinity for Hb vs O2; 100% O2 halves CO-Hb half-life from 5 h to 1 h; hyperbaric for severe (CO-Hb >25% or pregnant or LOC) → tox.co-poisoning.core.v1)
5. ceftriaxone + vancomycin + ampicillin + dexamethasone Ceftriaxone 2 g IV q12h; vancomycin 15-20 mg/kg IV (loading); ampicillin 2 g IV q4h (age >50 / immunocomp / pregnant); dexamethasone 10 mg IV q6h x 4 days IV per agent above — Suspected bacterial meningitis (fever + AMS + meningismus / petechiae / age >50 risk); start WITHIN 1 H (IDSA bacterial meningitis (Tunkel PMID 22119250 — verify) — empiric coverage + dexamethasone BEFORE first abx dose; route to id.bacterial-meningitis.core.v1)
6. acyclovir 10 mg/kg IV q8h (renal adjust) IV q8h x 14-21 days — Suspected HSV encephalitis (fever + AMS + temporal-lobe MRI findings OR CSF lymphocytic pleocytosis with negative bacterial workup); empiric while HSV PCR pending (HSV encephalitis has 70% mortality untreated; empiric acyclovir while awaiting CSF HSV PCR; no dedicated dossier — consult-based / general ID workflow)
7. lorazepam (status epilepticus first-line) 4 mg IV (or 2 mg if elderly/small); may repeat in 5-10 min IV once then repeat once — Active convulsive seizure OR nonconvulsive status on EEG (Brophy NCS 2012 — benzodiazepine first-line for status; then load AED (levetiracetam 60 mg/kg or fosphenytoin 20 PE/kg) → neuro.status-epilepticus.core.v1)
8. hydrocortisone (adrenal crisis) 100 mg IV bolus then 50 mg IV q6h or 200 mg/24 h infusion IV bolus + q6h — Suspected adrenal crisis (known adrenal insufficiency or steroid-dependent + AMS + hypotension + hyperK + hypoNa) (Empiric stress-dose steroids before cortisol/ACTH results; route to endo.adrenal-crisis.core.v1)
9. levothyroxine + hydrocortisone (myxedema coma) Levothyroxine 200-400 mcg IV bolus then 50-100 mcg IV daily; hydrocortisone 100 mg IV q8h until adrenal axis confirmed IV bolus + maintenance — Suspected myxedema coma (hypothermia + bradycardia + hyponatremia + AMS + known/likely hypothyroidism) (Myxedema coma has 30-50% mortality; thyroid hormone + steroid + passive rewarming + supportive care → endo.myxedema-coma.core.v1)
10. propylthiouracil or methimazole + propranolol + hydrocortisone (thyroid storm) PTU 600-1000 mg PO load then 200-300 mg q4h; OR methimazole 60-80 mg PO then 30 mg q6h; propranolol 60-80 mg PO q4h; hydrocortisone 100 mg IV q8h; iodine 1 h after PTU PO + IV per agent — Suspected thyroid storm (Burch-Wartofsky ≥45 or fever + tachycardia + AMS + GI distress + known thyrotoxicosis) (Thyroid storm has 10-30% mortality; PTU/methimazole + beta-blocker + steroid + iodine + supportive → endo.thyroid-storm.core.v1)
11. lactulose + rifaximin (hepatic encephalopathy) Lactulose 30 mL PO/PR q1-2h initially then titrate to 2-3 soft stools/day; rifaximin 550 mg PO BID PO/PR titrate — Cirrhotic + AMS + asterixis + elevated ammonia → hepatic encephalopathy West Haven grade III/IV (AASLD 2014 HE — lactulose first-line; rifaximin add-on; treat precipitant (GI bleed, SBP, constipation, dehydration, sedatives) → gi.hepatic-encephalopathy.core.v1)
12. N-acetylcysteine (acetaminophen overdose) IV: 150 mg/kg over 1 h, then 50 mg/kg over 4 h, then 100 mg/kg over 16 h (Rumack-Matthew nomogram positive at 4 h post-ingestion) IV per protocol — Acetaminophen level above Rumack-Matthew treatment line OR concerning unknown ingestion timing (NAC near-100% hepatoprotective if started within 8 h; still beneficial >24 h post-ingestion in hepatotoxicity → tox.acetaminophen-overdose.core.v1)

Non-pharmacologic actions:
- Two large-bore IVs
- Airway protection — intubate if GCS ≤8 OR loss of gag/cough OR severe agitation requiring procedural sedation
- Foley catheter for urine output and to rule out UTI source in elderly delirium
- Continuous cardiac telemetry
- NPO until disposition + airway assessment
- Family at bedside (delirium prevention) + sensory aids (glasses, hearing aids)
- Sitter for safety if agitation / fall risk
- Neuro consult for stroke / ICH / SAH / status epilepticus
- ID consult for meningitis / encephalitis / sepsis with unclear source
- Endocrine consult for thyroid storm / myxedema coma / adrenal crisis
- Hepatology for hepatic encephalopathy refractory to lactulose
- Psychiatry consult for primary psychiatric AMS (only after medical workup negative)
- Tox consult for complex overdose

Monitoring

Setting (ed) monitoring:
- GCS / FOUR / CAM / RASS reassessed at minimum q1h initially then q4h
- Vital signs q15 min × 1 h then q30 min × 4 h then per disposition
- Continuous SpO2 + telemetry
- Serial fingerstick glucose q1-2h if hypoglycemia or DKA/HHS treated
- Na correction rate ≤8 mEq/L/24 h (osmotic demyelination risk from rapid correction of chronic hyponatremia)
- Serial Cr + lactate clearance for resuscitation adequacy
- Urine output goal ≥0.5 mL/kg/h
- I/O monitoring; fluid balance
- Seizure precautions if active or recent seizure

Follow-up plan: 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
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: 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

Disposition

Current setting: ed — Universal AMS bundle (glucose / thiamine / naloxone / O2 / airway); rule out life-threats (hypoglycemia / hypoxia / opioid / status epilepticus / meningitis / stroke / ICH / SAH / DKA / HHS / thyroid storm / myxedema coma / adrenal crisis / sepsis / Wernicke); risk-stratify with GCS / FOUR / CAM / qSOFA; route confirmed phenotype to dedicated engine (Wijdicks 2008 PMID 18193394; Inouye 2014 PMID 22504182; Wernicke-Korsakoff PMID 32553711)

Disposition criteria:
- Discharge: reversible AMS (hypoglycemia fully treated; mild medication-induced delirium with offending agent stopped; alcohol intoxication after observation with normal mentation) + reliable home + close PCP follow-up ≤24-48 h + return precautions
- Observation: pending serial reassessment (delirium not yet cleared; partial metabolic correction; pending CT/MRI/LP results)
- Admit ward: persistent delirium needing workup; mild-moderate sepsis without organ failure; mild hyponatremia/hypernatremia under controlled correction
- ICU: GCS ≤8; intubated; status epilepticus; DKA/HHS with refractory acidosis; thyroid storm / myxedema coma; adrenal crisis; severe sepsis; ICH/SAH; large stroke pending thrombectomy; toxic alcohols on dialysis; severe acetaminophen with hepatic failure
- Psych admit: primary psychiatric AMS (medical workup negative; psych dx confirmed)

Escalation triggers (move to higher acuity):
- GCS ≤8 OR loss of airway reflexes → INTUBATE + ICU
- Hypoglycemia refractory to D50W → octreotide if sulfonylurea overdose; glucagon if no IV; ICU for continuous D10W infusion
- Status epilepticus refractory to benzo + first-line AED → second-line AED + intubation + continuous EEG + ICU → neuro.status-epilepticus.core.v1
- Suspected bacterial meningitis → abx within 1 h + LP after CT; route to id.bacterial-meningitis.core.v1
- Suspected HSV encephalitis → empiric acyclovir + MRI + CSF HSV PCR + ICU
- Suspected ischemic stroke (LKW <24 h, focal deficit) → STAT CTA + tPA/thrombectomy pathway → neuro.ischaemic-stroke.v1
- Suspected ICH → BP control (SBP 130-150) + reversal of anticoag + neurosurgery → neuro.ich.core.v1
- Suspected SAH (thunderclap headache + AMS) → CTA + neurosurgery (clipping/coiling) → neuro.sah.core.v1
- DKA / HHS → insulin infusion + IVF + K replacement → endo.dka.core.v1 / endo.hhs.core.v1
- Thyroid storm (Burch-Wartofsky ≥45) → PTU + beta-blocker + steroid + iodine + ICU → endo.thyroid-storm.core.v1
- Myxedema coma (hypothermia + AMS + bradycardia + hyponatremia + known hypothyroid) → levothyroxine + steroid + ICU → endo.myxedema-coma.core.v1
- Adrenal crisis → hydrocortisone 100 mg IV + IVF + ICU → endo.adrenal-crisis.core.v1
- Severe hyponatremia / hypernatremia → controlled correction + ICU → syndrome.hyponatremia.core.v1 / hypernatremia
- Hepatic encephalopathy West Haven grade III/IV → lactulose + rifaximin + ICU → gi.hepatic-encephalopathy.core.v1
- Sepsis (qSOFA ≥2 OR lactate >2) → bundle within 1 h → id.sepsis.core.v1
- CO poisoning (CO-Hb >25% OR LOC OR pregnant OR ischemia) → 100% O2 + hyperbaric → tox.co-poisoning.core.v1
- Acetaminophen overdose (Rumack-Matthew positive) → NAC → tox.acetaminophen-overdose.core.v1
- Toxic alcohols (osmolar gap + metabolic acidosis) → fomepizole + dialysis → tox.toxic-alcohols.core.v1
- Salicylate overdose (level >40 mg/dL OR severe acidosis OR AMS) → urinary alkalinization + dialysis → tox.salicylate-overdose.core.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Fingerstick glucose <70 mg/dL with AMS — D50W 50 mL IV stat; thiamine BEFORE glucose in alcoholics (PMID 32553711)
- [LIFE_THREATENING] Pinpoint pupils + bradypnea + AMS — naloxone 0.4-2 mg IV/IM/IN; titrate to RR; consider infusion for long-acting opioids (methadone, fentanyl analogs)
- [LIFE_THREATENING] Sudden focal deficit + AMS + LKW <24 h → STAT non-contrast head CT + CTA + tPA/thrombectomy pathway (Powers AHA 2019)

Citations

- 2008 Wijdicks NEJM coma + 2014 Inouye NEJM delirium + Wernicke-Korsakoff Guidelines 2020 + 2017 Tunkel IDSA encephalitis + 2019 Powers AHA stroke + 2012 Brophy NCS status epilepticus + 2026 SSC sepsis + AASLD HE 2014 + ADA 2026 + IDSA bacterial meningitis 2008 [PMID:39353612](https://pubmed.ncbi.nlm.nih.gov/39353612/)
- Cited evidence (PMID 20709246) [PMID:20709246](https://pubmed.ncbi.nlm.nih.gov/20709246/)

Last reconciled with current guidelines: 2026-05-30.

References

2008 Wijdicks NEJM coma + 2014 Inouye NEJM delirium + Wernicke-Korsakoff Guidelines 2020 + 2017 Tunkel IDSA encephalitis + 2019 Powers AHA stroke + 2012 Brophy NCS status epilepticus + 2026 SSC sepsis + AASLD HE 2014 + ADA 2026 + IDSA bacterial meningitis 2008 — PMID:39353612
Cited evidence (PMID 20709246) — PMID:20709246

Clinical Commander