Using AEIOUTIPS For Altered Mental States

The AEIOUTIPS acronym holds a special place in my paramedic heart. It stands alongside OPQRST and SOAP as one of the three most useful acronyms I ever learned in medicine.

I’m a believer in AEIOUTIPS for several reasons.

Unlike mnemonics like my first cardiac arrest algorithm, (Shock, shock, shock. Everybody shock. Little shock, big shock, big shock, little shock.) AEIOUTIPS has remained relevant. That helpful cardiac arrest rhyme may have helped me through my first ACLS class, but it barely lasted through my first year as a paramedic. Once someone thought up high dose Epinephrine, things got complicated.

And, unlike more well known acronyms such as DCAP-BTLS-TIC, AEIOUTIPS has actual clinical application. That means I actually run through it in my head while I’m in the middle of patient care. I have never once exposed a trauma patients chest and actually though to myself, “OK, I don’t see any deformities…and I don’t see any contusions…and I don’t see any abrasions…” You see my point.

So what is this AEIOUTIPS acronym? It’s an acronym to help you remember the most common causes of altered mental status (AMS). This is useful when your patient is anything less than alert and oriented and you can’t figure out why.

Let’s face it, some differential diagnosis jump out at you. It isn’t tough to figure out what’s really¬† wrong with the dude that got hit by a car. The COPD patient who’s tripoding and breathing 30 shallow breaths a minute isn’t much of a mystery either. But the confused or unconscious patient can be a real puzzler.

The next time your patient has an altered mental status and you find yourself puzzled by what’s going on, manage the basics and run through the AEIOUTIPS acronym in your head.

A is for alcohol.

It’s first on the list for a reason. Alcohol plays a roll is a large percentage of the altered mental states that we encounter. Sometimes it’s obvious. Other times it isn’t. Does the patient have an odor on their breath? Does their environment suggest alcohol consumption?

E is for epilepsy (and other forms of seizure).

Could the patient have had a seizure? Inquire about the patients medical history and check their prescription medications. Do you note any oral trauma or urinary incontinence? Look closely for repetitive focal movement. Was the onset of altered mentation sudden?

I is for insulin.

Check the refrigerator (Insulin), the medicine cabinet and the patients body (Medicalert tags) for evidence of diabetes. Could the patient be hypoglycemic (or possibly hyperglycemic). Don’t forget a routine glucose check on all of your altered mental status patients. The ones we can’t figure out tend to always get their blood glucose checked. It’s when we are convinced that the cause of altered mentation is something else on the list that blood sugar can sneak up on us. Most of us have at least one good story about the stroke or the seizure that turned out to be a hypoglycemic event.

O is for overdose (and oxygenation).

If medication bottles are present, does the pill count add up? Is there evidence of drug use at the scene? We discussed alcohol, but don’t forget about other substances that can cause mental status changes. Consider opiates (and check those pupils). Hallucinogens, deliriants and inhalants also produce altered mentation to varying degrees. They account for some of our more unusual mental status presentations.

Also consider an acute hypoxic event. Airway patency, lung sounds and skin should be evaluated early. If the patient is on home oxygen ensure that the supply is uninterrupted.

U is for uremia (or underdose).

Does the patient have a history of renal failure or renal disease? Have they been urinating? Look for signs of increased toxins (mainly nitrogen) in the blood like jaundice, recent fatigue, dehydration, unusual thirst and peripheral swelling.

Some folks also add “underdose” or non-compliance to medication to the U category. Medication non-compliance can contribute to altered mental states, but the true cause of altered mentation will, most likely, be found somewhere else on this list. Is the patient taking their prescribed medications?

T is for trauma.

Could there have been an unreported traumatic event? Could the patient have been assaulted? Could there have been a previous head injury that lead to the current change in mental status? (Think lucid interval.) Your assessment should include a through look at the head as well as a search for causes of occult bleeding in the chest abdomen and pelvis.

I is for infection.

Is there a source of infection? Has the patient been ill recently? Is the patient immuno-compromised? Are they in a high risk category for sepsis such as kids, the elderly, and patients taking chemotherapy and immuno-suppressive therapies? Feel the patient skin. Take a temperature if you have that ability. Pay close attention to the blood pressure. Most of our sepsis patients will show some degree of hypotension before they become noticeably altered.

P is for psychiatric (and poisoning).

This is one where non-compliance to medications can be an important precipitating factor. Does the patient have a history of psychiatric events? Could the current presentation be a simple episode of catatonia or some sort of psychosis? Psychiatric disorders can precipitate some unusual, what-the-heck-is-going-on type presentations. If you feel like you’ve ruled out everything else, consider an acute psychotic episode.

Also consider the possibility of poisoning, both intentional and unintentional.  Consider the environment where the patient was found. Could the patient have had contact with a poison. Consider that ingestion is only one potential route for poisons. Chemicals like organophosphates can be absorbed through the skin and carbon monoxide is inhaled.

S is for stroke (and shock).

Not just occlusive stroke, but anything that might put pressure on the brain. This includes lesions, tumors and spontaneous hemorrhage. Do a thorough neurological evaluation and look for motor deficits in the patients response to stimuli. Note muscular weakness in the face and take a good look at the pupils.

While we specifically addressed hypovolemic shock and septic shock, consider other causes of shock like cardiogenic and anaphylactic shock. Pay close attention to the patients hemodynamic stability and consider an underlying shock state.

AEIOUTIPS takes a little practice. Your first few times working through the acronym will feel awkward. But with a little time and patience, the memory tool can become a trusted friend during some of your more challenging calls. I’ve talked through these nine points out loud with my partner on the way to the hospital when an altered patient us both scratching our heads over what was going on.

While I may not always nail the cause of altered mental status, I rarely find an altered patient who falls outside of the AEIOUTIPS list.

Now it’s your turn. Did you learn the AEIOUTIPS acronym in school? Do you use it during patient care?

Read more EMT awesomeness:

LCES for EMTs

The Ultimate EMS Protocol

The SOAP Reporting Breakthrough

Understanding OPQRST

Learning DCAPBTLS (A Word of Advice)

Comments

  1. My wilderness first responder instructor had a different mnemonic for causes of altered mental status: STOPEATS.

    Sugar
    Temperature
    Oxygen
    Pressure
    Electricity
    Altitude
    Toxins
    Salts

    Obviously, some of these (altitude, for example) aren’t as relevant in a street setting, but I wouldn’t mind hearing opinions on this mnemonic.

  2. Thanks for a great detailed version. It is in our current EMT book but little emphasis was put on it. And I completely agree that dcap btls is a silly one.

  3. Learned it in EMT school and it’s been mentioned a few times in medical school, but I don’t use it. For something like altered mental status, the absolute best thing to do is to conduct a full and proper history and physical. If you’re an EMT who can check blood glucose levels or a paramedic, you should be doing so for every patient with an altered mental status, not just because you’ve ruled out “A” and “E”, and are now at “I,” but because a proper evaluation for this patient requires a blood glucose check.

    I think one of the biggest problems with memory tools like AEIOUTIPS is that the assessment becomes a hunt for the one cause, to the exclusion of other possibilities. What about acid/base in balances or electrolyte disturbances? What if there are two events going on now (say, the patient with ESRD suffered a stroke, and now is uremic, and no one noticed until he missed his dialysis appointment the next day)?

    Assessment is key, not memory aids.

  4. Steve Whitehead says:

    @Danny I like this. In fact…it could be a whole other post. You are correct that it is wilderness specific. But in that setting it would be a very useful tool.

  5. Steve Whitehead says:

    @Jeremy Thanks. It’s unfortunate that we spend so much time on DCAP BTLS TIC and so little time on really useful memory aids like AEIOU TIPS.

  6. Steve Whitehead says:

    @Joe Thanks for your post. You bring up a very good point. Like any memory tool…or any tool for that matter, this tool can be used and it can be misused. If it is used to help the responder cover all of their bases it can be a great asset.

    We recently had an ER physician tell a story during a CE class about the time he called for an emergent neurology consult only to have the neurologist hand him the blood work and politely ask that the patients blood sugar be corrected before the evaluation continued. Once the Doc fixed the hypoglycemia, the patient became asymptomatic.

    Your right, tunneling in on the wrong diagnosis to the exclusion of others can be a big mistake. Hopeful, caregiver are using tool like this to cover their bases, not tunnel in.

    Thanks for your insight.

  7. I never learned this acronym in school. I also didn’t learn the “TIC” in DCAP-BTLS or SOAP.

    Apparently, Pennsylvania is missing out on some of the good stuff.

    Anyone willing to feed a curious mind and fill me in on these things?

  8. Anonymous says:

    im really learning from this post..im volunteer emt from Philippines and i must admit, we really need updates..im thankful for this post

  9. How about “COMA”?

    C = Carbon Monoxide

    O = Overdose

    M = Metabolyc (glucose, uremyc, haepatic, etc)

    A = Aneurism (Stroke, seizures, head trauma)

  10. TIC can be included in the BTLS for trauma what your looking for:

    Tenderness-Instability-Crepitis

  11. I have another mnemonic for the same and I find that quite useful but yours is good too and very nearly a complete list. Whatever works man.
    The idea of using memory aid is to stick to the same pattern everytime and not to miss anything in as little time as possible.

    As medics you will be required to sit for exams regularly all your life. This is when mnemonics is gold. You can go through them and your exam preparation is made so much easier and you save time trying to memorise causes.
    With the aid of a mnemonic you can verbal diarrhoea out the causes confidently to the examiner. This ofcourse will then be reflected on your scores!! More positives for you.
    Cheers man. G’luK with all the life saving and have a quiet one today.

  12. Marguerite says:

    I love AEIOUTIPS for thoroughness but I teach my students “ToSTOP” for ease of learning…

  13. I was reminded of this pneumonic earlier this week, and deliberately looked it up which lead me to your site. I as a EMR who is entering into the next level of learning am loving these. Sure I vaguely remember using them in school, but now that I’ve been in the field in some slower stations its harder to use and even though I should have been I haven’t. So I’m really glad for this detailed list, I’m sure it’s going to help me with my studying!! And Patient assessments.

  14. Hi, i find myself which i recognized you actually visited my weblog and so i arrived at returning a like? . I am looking for points to increase our web page! Perhaps the sufficient to utilize a number of your current ideas!

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