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Surgical sieve
😵 Drowsy / reduced GCS
Airway, glucose, pupils — in that order, before any differential. Then: is this toxic, metabolic or structural? Asymmetric pupils or focal signs mean structural until a scan says otherwise. If the patient is AWAKE but thinking badly, use the Confusion / delirium card instead — the work there is causal and there is time.
| Hypoglycaemia Must exclude | Sweaty, aggressive or flatly unrousable. Insulin, sulfonylureas, alcohol, liver disease, poor intake, or an overnight fast before a procedure.A capillary glucose in EVERY drowsy patient, before anything else. It takes twenty seconds and it is the most reversible thing on this list. |
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| Opioid-induced hypoventilation Must exclude | Pinpoint pupils, a respiratory rate under 10, and progressive sleepiness. After a PCA, an epidural, a dose increase, or renal impairment causing accumulation.Naloxone, titrated in small doses — the aim is to restore breathing, not to reverse analgesia and leave them in agony. |
| Intracranial haemorrhage Must exclude | A falling GCS, asymmetric or fixed pupils, focal weakness, or Cushing's response — hypertension with bradycardia. Anticoagulation and a head strike, however trivial.Urgent CT head and reverse the anticoagulant. Do not wait for deterioration to declare itself further. |
| Meningitis / encephalitis Must exclude | Fever with a reduced conscious level, headache, neck stiffness or seizure. Encephalitis presents as behaviour change and confusion more often than as neck stiffness.Antibiotics and aciclovir without waiting for the LP or the CT. |
| Sepsis (any source) Must exclude | In the elderly, a reduced conscious level may be the presenting feature with no fever and no localising symptoms.Sepsis Six. A full set of observations including the temperature and the glucose. |
| Stroke Must exclude | Sudden onset with focal signs. A basilar or large posterior stroke can present as drowsiness with few limb signs at all.Glucose first, then urgent CT and a stroke call. Establish the time last known well. |
| Type 2 respiratory failure Must exclude | Drowsy, flushed, bounding pulse, asterixis — often in a COPD patient who has been on uncontrolled oxygen for a few hours.A blood gas, not a saturation probe. Controlled oxygen and consider NIV. |
| Drug toxicity or withdrawal Time-sensitive | Benzodiazepines, antipsychotics, antiepileptics, lithium, or a deliberate overdose. Pupils, respiratory rate and tone narrow it down.Read the chart and check what changed in the last 24 hours. TOXBASE. Flumazenil is rarely the right answer and can precipitate seizures. |
| Post-ictal state Time-sensitive | Gradually improving drowsiness after a witnessed or suspected seizure, with a bitten tongue, incontinence or Todd's paresis.Reassess the conscious level frequently and serially, at an interval you document. A post-ictal state that is NOT improving is not post-ictal — think non-convulsive status or a structural cause. |
| Hepatic encephalopathy Time-sensitive | Asterixis, jaundice, ascites, and a precipitant — GI bleed, infection, constipation, sedation, dehydration. Most cases are decompensated CHRONIC liver disease.Lactulose and find the precipitant. Ammonia correlates poorly and does not guide treatment; do not wait for it. If there is ACUTE liver injury with coagulopathy and no known cirrhosis, consider acute liver failure and open that pathway. |
| Electrolyte derangement Time-sensitive | Sodium is the usual culprit — both directions, and the speed of change matters more than the absolute number. Also calcium, magnesium and glucose.U&E, bone profile, magnesium. Correcting sodium too quickly causes the harm it is meant to prevent. |
| Wernicke's encephalopathy Time-sensitive | Confusion, ataxia and eye signs — but the full triad is present in a minority, so treat on suspicion.Parenteral thiamine BEFORE any glucose. Giving glucose first can precipitate it. |
| Raised intracranial pressure / mass Time-sensitive | Progressive drowsiness with morning headache, vomiting, papilloedema or new focal signs. Known malignancy raises this a long way up the list.Image before any lumbar puncture. Dexamethasone for vasogenic oedema on senior advice. |
| Hypothermia Time-sensitive | A core temperature that a standard tympanic thermometer may not read low enough to report. Long lie, elderly, alcohol, hypothyroidism.A LOW-READING thermometer. Rewarm gradually and handle gently — rough handling can precipitate VF. |
| Addisonian crisis Consider | Drowsiness with hypotension, hyponatraemia, hyperkalaemia and hypoglycaemia. Ask about long-term steroids stopped, missed, or not doubled during illness.Hydrocortisone 100mg IV without waiting for a cortisol. |
15 differentials · 10 open a full pathway in the app.