In this episode of Hospital Medicine Unplugged, we blitz status epilepticus (SE)—recognize at 5 minutes, give a full benzo dose fast, load a second-line ASD without delay, and escalate to ICU infusions + EEG when needed.

We open with the do-firsts (0–5 min): ABCs, oxygen, lateral positioning, monitors, IV/IO access, check glucose (give thiamine → dextrose if at risk), draw labs, consider tox screen, and don’t miss mimics. If persistent altered consciousness, order EEG early to uncover nonconvulsive SE.

Diagnosis & triage: SE = continuous seizure ≥5 min or recurrent seizures without recovery. Includes convulsive and nonconvulsive phenotypes; the latter is subtle—EEG is essential. Etiology buckets: structural (stroke/ICH/tumor/TBI), metabolic (electrolytes, organ failure), withdrawal/intoxication, medication non-adherence, autoimmune/NORSE, infection. Etiology predicts outcome—hunt it while you’re treating.

First-line (5–10 min): benzodiazepine—full dose, once, fast.
• IV lorazepam 0.1 mg/kg (max 4 mg); or IV diazepam 0.15–0.2 mg/kg (max 10 mg).
• No IV? IM midazolam 10 mg (or IN/buccal 0.2 mg/kg).
Speed and adequate dosing beat agent choice. Repeat once if still seizing and move on.

Second-line (10–30 min): established SE—levetiracetam, fosphenytoin, or valproate.
• Levetiracetam 60 mg/kg (max 4.5 g), fosphenytoin 20 mg PE/kg (max 1.5 g PE), or valproate 40 mg/kg (max 3 g)—similar efficacy, choose by comorbidity/contraindications.
• Levetiracetam/valproate favored in cardiac disease; avoid valproate in pregnancy or severe hepatic disease.
• Consider lacosamide if alternatives limited.

Refractory SE (30–60+ min): seizures persist after a benzo + one second-line ASD → ICU, intubate, start continuous EEG and anesthetic infusions:
• Midazolam or propofol (titrate to seizure or burst suppression).
• Watch for hypotension, infection, metabolic complications; protocolize weans to avoid withdrawal seizures.

Super-refractory (>24 h after anesthetics): broaden playbook—ketamine, additional ASDs, immunotherapy for suspected autoimmune/NORSE, ketogenic diet, neuromodulation (VNS/ECT), selective inhaled anesthetics, and surgical options for focal, resectable sources. Multidisciplinary team is non-negotiable.

EEG strategy that sticks: spot NCSE early; in refractory phases, continuous EEG guides infusion targets and catches breakthroughs. Diagnostic IV ASD trials under EEG can clarify ambiguous patterns.

Setting-specific pearls:
• Alcohol withdrawal: benzodiazepines are primary; thiamine before glucose; phenytoin doesn’t treat withdrawal seizures.
• Pregnancy: benzos for emergent control; levetiracetam or fosphenytoin next; avoid valproate when possible; magnesium for eclampsia.
• Older adults: same ladder, but dose-low/go-slow, mind renal/hepatic function and drug–drug interactions.

Why the hurry? Prolonged seizures shift receptors (↓GABA, ↑NMDA), fue

In this episode of Hospital Medicine Unplugged, we race through delirium in hospitalized adults—spot it early, fix the causes, deploy bundles, and medicate only when safety’s at stake.

We open with the scale and stakes: delirium hits ~11–42% of general inpatients and up to 87% of older surgical patients, driving falls, longer LOS, institutionalization, cognitive/functional decline, and higher mortality. Hypoactive phenotypes hide in plain sight—look for inattention + fluctuation.

Diagnosis & risk stratification—make screening routine:
• Bedside tools: CAM (and Short-CAM/3D-CAM), 4AT, CAM-S (severity).
• Method: pair direct interview with chart review; anchor on acute onset, inattention, fluctuating course, ± disorganized thinking or altered consciousness.
• Risk factors: age, baseline cognitive impairment, sensory loss, dehydration, sleep deprivation, polypharmacy (+ benzodiazepines/anticholinergics/opioids), infection, metabolic derangements.

Prevention—build the nonpharmacologic bundle (it works):
• Multicomponent programs cut incident delirium ~43–53% vs usual care.
• Core moves: frequent reorientation & cognitive stimulation; early mobilization; sleep hygiene (cluster care, lights/noise control); hydrate & nourish; vision/hearing optimization (glasses, hearing aids); family engagement; minimize tethers/restraints.
• Models: HELP on wards; ABCDEF in ICU (pain/light sedation, delirium monitoring, early mobility, family).

Management—treat delirium like acute brain failure:
• First line is always nonpharmacologic + rapid hunt/correct contributors: meds (de-prescribe anticholinergics/benzos when possible), hypoxia, infection, electrolyte/renal/hepatic issues, pain, urinary retention/constipation, withdrawal states.
• Environment: daylight cues by day, quiet/dark at night; clocks/calendars; familiar objects; bladder/bowel care.
• Mobilize early, restore circadian rhythm, avoid physical restraints whenever possible.

When agitation endangers care or safety:
• Antipsychotics (off-label) only for severe agitation: start low-dose haloperidol (e.g., 0.5–1 mg) or consider quetiapine/olanzapine if EPS/QTc risk; use the lowest effective dose for the shortest time. They do not shorten delirium—they just help you get through essential care safely.
• Avoid benzodiazepines except for alcohol/benzo withdrawal.
• Melatonin/ramelteon: mixed evidence; not routine.
• Always re-evaluate daily and de-escalate fast.

Setting-specific pearls:
• ICU: screen with CAM-ICU/ICDSC; keep sedation light; dexmedetomidine may beat benzos for ventilated patients; execute ABCDEF.
• Post-op: proactive geriatric co-management, opioid-sparing analgesia, regional techniques when appropriate, early mobilization/sleep protection.
• Palliative/end-of-life: prioritize comfort and distress reduction; short courses of antipsychotic for severe symptoms after family-aligned goals-of-care discussions.

Prognosis—why urgency matters:
• Delirium tracks with higher in-hospital mortality, prolonged stays, discharge to facilities, and long-term cognitive decline; risk rises with duration of delir