New confusion / reduced GCS

Act now

1. 1

   Glucose <4 mmol/L: treat as hypoglycaemia.

3. 2

   Suspected opioid toxicity with reduced RR: naloxone, titrated in small increments (see BNF) — smaller doses in palliative or long-term opioid patients.

5. 3

   GCS ≤8: call anaesthetics for airway support.

Assess

• ABCDE; protect the airway. Record GCS (or ACVPU) and pupils.
• Check capillary glucose immediately.
• Review drug chart: opioids, benzodiazepines, sedatives, anticholinergics, new antibiotics; alcohol withdrawal.
• Focal neurology or sudden onset: think stroke or intracranial bleed (especially if anticoagulated or after a fall).

Investigations

• Venous/arterial gas (CO₂, glucose, Na⁺), U&E, Ca²⁺, LFTs, ammonia if liver disease, FBC, CRP, cultures, ECG.
• CT head if focal signs, head injury, anticoagulated, or no clear metabolic cause.

Manage

• Treat the cause. If confusion without reduced consciousness, use the 4AT to assess for delirium (see Confused patient).
• Suspected alcohol withdrawal or malnutrition: IV thiamine before glucose where possible.

Escalate when