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What to Do When the Victim's Confused and So Are You

by James Hubbard, MD, MPH

You’re in the midst of a storm. The streets are dangerous for travel. There’s no electricity and cell phones are not working. You notice movement outside your window and watch your neighbor drop slowly to the ground.

After making sure the scene is safe—no strange, suspicious-looking people or animals, etc.—you grab your pepper spray, just in case, and go out to check on him.

He’s awake but lethargic, says he’s just not feeling well and wants to sleep. He lives alone and was coming over to your house for help.

You have no idea what’s going on, and he’s no help. In fact, he’s snoring now.

What can you do? The possible causes of an altered mental status make up a pretty long list if you include the many you’re probably not going to think of.

Well, how about doing what we medical people do sometimes? Use a special trick to sort through common causes and then decide your next steps.


We in medicine love using memory tricks called mnemonics. They not only jog our memory but better ensure we’re not missing any details.

Here’s my personal example of their power. Way back in my first year of medical school, I learned a little phrase to remember the 12 cranial nerves, in the proper order. Now these days, in my practice, I seldom have need for that bit of knowledge, and I could always look it up. But the fact is, it’s stuck in my brain, and I’ll likely never forget it.  And all because of a silly mnemonic, “On old Olympic’s towering top a Fin and German viewed some hops.” The first letter each of the words is the first letter of a cranial nerve:. CN 1 is olfactory, 2 is optic, and so on.

I don’t know about other professions, but in medicine, memory tricks like that can give us that little edge when our brains are tired or overwhelmed.

And so to the task at hand. AEIOU TIPS is a memory jogger for the causes of an altered mental status, like when someone is confused or lethargic.

Caution: An altered mental status is reason to get professional emergency medical help. Most suggestions below are for if that is impossible.

Alcohol. Usually it’s obvious by the smell or bottles around. And it can make the person anywhere from tipsy to almost comatose. Treatment is to wait and watch. If the person is deeply asleep, try turning and propping them on their side. Coffee, etc., is not going to help, and the extra fluid could increase the risk of vomiting.

Epilepsy (seizures). If the person’s had an epileptic seizure before, that’s a clue that this could be another one. Other clues could be active jerking or bites on the tongue. Or they may have a health bracelet, necklace, or card, or a bottle of antiseizure medicine. Sometimes it takes a person a few minutes to wake up completely after an epileptic seizure. Turn them on their side if they’re having trouble breathing. Otherwise just give them some space and be there as they wake up. (Read more about how to help someone having a seizure here.)

Insulin. People who take insulin for diabetes, even if they take the same dose they usually take, can sometimes lower the blood sugar to dangerous levels. The first sign can be confusion or agitation, or a coma. A clue that insulin is the cause could be an insulin bottle; an insulin pump; or an alert card, bracelet, or necklace. If they’re alert enough to swallow, give them a little food or juice. If they’re not, it might take an injection of glucagon (someone who takes insulin might have it on them, in the car, or in the house) or injectable glucose given into a vein.

Overdose. Sedatives, opiate pain medicines, and recreational drugs are common. Look for bottles or needle tracks on the arms. Pinpoint pupils that don’t get larger in the dark is a clue for an opiate overdose. Some addicts may have the opiate antidote naloxone on hand in injectable or nasal form.

Uremia. This is a buildup of toxics from renal disease. Unless you knew the person had kidney disease, this would be a hard one to diagnose. And I don’t know what you could do in the field anyway since dialysis is the treatment.

Trauma. I’ve gone into trauma assessments and treatments in multiple posts. (Here’s one on head trauma and one on concussions.) In my thinking, trauma should almost always be considered. Even if you suspect another cause for the altered state, that doesn’t mean the altered state couldn’t have resulted in trauma. For instance, a fall or car accident after a seizure could cause injury; too much alcohol could cause a bad bleed that if not treated immediately could result in death.

Infection from a wound or an illness. Another hard one to diagnosis unless there’s a high fever or someone knows the person has been sick—or, I guess, unless you find some really bad skin infection on your exam.

Psychiatric. Look for psychiatric medicines.
Poisons. Again look for bottles. Consider carbon monoxide (immediate treatment being fresh air).

Stroke Signs: Act FAST

Think someone might be having a stroke? Think FAST, per the National Stroke Association:

  • Face drooping? Ask the person to smile to see if one side of the mouth droops.
  • Arm weakness or numbness? Ask them to raise their arms to see if one side is weaker.
  • Speech slurred?
  • Time! Reminds you that these days, strokes are treatable, even reversible. The sooner you can get the person to a medical facility the better chance they have.

Stroke. Maybe a clue would be blood pressure bottles or the fact that the person is older. (Stroke is more common in older people, but any age person can have one.) Better: The National Stroke Association has come up with their own mnemonic, FAST, to help you quickly recognize a stroke (see insert).

Like almost all mnemonics, AEIOU TIPS can be a great help but doesn’t list all the reasons for an altered status. Hypothermia, hyperthermia, and dehydration come to mind.

Still, in an emergency, it can be a big help and remind you to check for causes you might otherwise forget.

So, you might ask, that’s great, but how will you remember the mnemonic, especially if you don’t use it very often? Good question. In the case of altered consciousness maybe by remembering that the person might need a tip to remember his AEIOUs.

I don’t know. I mean, after all these years, why do I remember “On old Olympus …”? Maybe it was just such an odd phrase, or perhaps it was from a basic fear common to most medical students: when asked, not knowing the answer. The mind’s a funny thing.

What about you? Have you ever used a memory jogger? Do you have a favorite?

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