Critical Cases - Acute Encephalopathy Emergency!

CC = acute confusion



  • 37 yo male acute onset of confusion and slurred speech 15 min prior to arrival
  • Was in his normal state of health prior to this, and had no complaints to co-workers during the work-day



  • Insulin dependent diabetes



  • Nonsmoker, occasional ETOH, no known drug use



T 97.7 oral

HR 65

BP 96/60

O2 sat 96% on RA



General: eyes closed, intermittently following commands, moving all extremities

HEENT: Pupils 3 mm and reactive. oropharynx clear

Cardio: no MRG

Pulm: lungs clear

Abd: soft, nontender

Neuro: GCS is Eye opening: 4, Verbal: 4 (confused speech) Motor: 6  = 14


Bedside diagnostics

  • Fingerstick glucose: 101
  • ECG: sinus rhythm, no ST/T wave changes, normal intervals


CT brain

  • Slightly degraded by motion artifact, no acute abnormalities




  • V = Vascular (ruptured AVM, SAH)
  • I = Iatrogenic (medications or street drugs)
  • N = Neoplasm (brain)
  • D = Degerative
  • I = Infectious (meningitis/encephalitis)
  • C = Congential
  • A = Autoimmune
  • T = Trauma (occult head trauma)
  • E = Endocrine, metabolic (hypoglycemia, hyperthyroid, hyponatremia, hypercalcemia)


Family arrives

  • Pt recently had his insulin regimen changed, and has had several episodes of hypoglycemia within the past week, often resulting in prolonged episodes of altered mental status


Case resolution

  • Repeat glucose at bedside = 58
  • 25g of dextrose administered
  • Pt immediately wakes up and returns to normal mental status, with no complaints
  • He is discharged home shortly afterwards after adjustment to sliding scale insulin

Teaching points

  • This patient's initial glucose was 101
  • Point of care glucose may not be accurate, or should be repeated in patients with suspected hypoglycemia
  • The clinical manifestations of hypoglycemia are variable in symptoms and severity
  • Hypoglcyemia is the #1 cause of acute change in mental status 
  • Consider empiric IV dextrose in any acute change in mental status in patients known or suspected to be taking insulin, regardless of point of care glucose readings