Vomiting with rapidly worsening confusion needs early ammonia testing before ICU delirium sedation and refractory ventricular fibrillation pad checks follow.
Vomiting with rapidly worsening confusion needs early plasma ammonia.
Vomiting with rapidly worsening confusion should get plasma ammonia into the first serious work-up, even when liver tests, imaging and lumbar puncture are unrevealing. Open the metabolic mystery first. It shows why severe non-cirrhotic hyperammonaemia cannot wait for a final genetic diagnosis: stop protein intake, give high-calorie glucose, seek urgent metabolic or critical care advice and prepare for renal replacement therapy if needed.
Agitated ICU delirium is the next bedside problem: use RASS and CAM-ICU before sedation, define calm and rousable, and do not over-read an early-stopped trial. The RCEM update gives a quick resuscitation check too: pad placement in refractory ventricular fibrillation should be truly lateral before vector change. For the next confused patient with vomiting, add ammonia before the standard tests make the case feel finished.
Start here when vomiting and rapidly worsening confusion are being explained by infection or neurology alone. Severe non-cirrhotic hyperammonaemia can have unremarkable liver tests, so plasma ammonia, protein cessation, high-calorie glucose and early metabolic or critical care advice change the case.
Agitated ICU delirium needs a target, not just more sedation. Use RASS and CAM-ICU together, define calm and rousable before dexmedetomidine, and remember the 4D signal was clearest for about one hour quicker agitation relief, with early stopping limiting certainty.
Cardiac arrest debriefs should include the defibrillator pads, not only timings. The RCEM update puts true lateral pad placement under the axilla and anterior-posterior vector change after three failed shocks ahead of routine dual sequential defibrillation.
Recurrent meningococcal disease or unexplained lip, face, airway or abdominal swelling should prompt immune pathway thinking. Complement 5 to 9 deficiency and hereditary angioedema are different problems, but both need recognition before repeated isolated episode management.
Nutrition counselling becomes safer when the first question is not protein grams. Ask about access, cost, transport and cooking facilities, then discuss fibre-rich plant foods, sodium, saturated fat and older-adult frailty risk without treating high-protein marketing as universal health advice.
When an adult has vomiting with worsening confusion, do not wait for liver disease to appear before checking ammonia. Add plasma ammonia early, especially after unrevealing imaging, lumbar puncture and routine blood tests. If severe hyperammonaemia is suspected, stop protein, give high-calorie glucose and seek metabolic or critical care advice.
When should plasma ammonia be added to the acute confusion work-up?
Add it early when vomiting, slurred speech, limb weakness or reduced consciousness progresses faster than the first differential explains. Normal liver tests and unrevealing imaging or lumbar puncture do not exclude severe non-cirrhotic hyperammonaemia.
What immediate actions are supported when severe hyperammonaemia is suspected?
Stop protein intake, start high-calorie glucose and seek urgent metabolic or critical care advice. Renal replacement therapy should be prepared early if severe hyperammonaemia persists or deterioration continues.
What should be defined before dexmedetomidine is used for agitated ICU delirium?
Use RASS and CAM-ICU together so the team separates agitation from delirium. Define the intended sedation target, such as calm and rousable, rather than simply giving sedation for restlessness.
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