Altered Level of Consciousness

Initial Approach

  • ABCs
    • Airway – talking, swallowing, gag reflex
    • Breathing – ventilation and oxygenation – mentation and O2 saturation.  Examine breathing pattern (Kussmaul, Cheyne-Stokes)
    • Circulation – peripheral circulation, feel pulses, capillary refill
  • C spine – mechanism of injury? Obvious facial lacerations/contusions
  • Disability: pupils – equal and reactive?  If no, consult neurosurgery!
  • GCS

* Best Eye Response. (4)

  • 1. No eye opening.
  • 2. Eye opening to pain.
  • 3. Eye opening to verbal command.
  • 4. Eyes open spontaneously.

* Best Verbal Response. (5)

  • 1. No verbal response
  • 2. Incomprehensible sounds.
  • 3. Inappropriate words.
  • 4. Confused.
  • 5. Orientated.

* Best Motor Response. (6)

  • 1. No motor response.
  • 2. Extension posturing.
  • 3. Flexion posturing.
  • 4. Withdrawal from pain.
  • 5. Localising pain.
  • 6. Obeys Commands.



IF 8 OR LESS INTUBATE!!!!

  • Monitors
  • O2
  • IV
  • Get a chemstrip

Initial Treatment

  • Thiamine 100mg IV
  • Dextrose – 1amp D50W IV push
  • Naloxone 2mg IV
  • REASSESS
  • Basic bloodwork as well as tox screen

Ongoing history and physical

General inspection:

  • HEENT:  Battle sign (basal skull fracture), rhinorrhea, otorrhea, neck stiffness
  • Skin:
    • Colour (cyanosis, hypoxia, abN Hgb)
    • Hydration
    • Needle tracks
  • Odor
  • Evidence of trauma

Neuro:

CN exam:

II         – Acuity: blink to visual threat

– Pupils: size, reactivity

– Fundoscopy: papilledema and hemorrhage

III,IV,VI                             – Gaze deviation (conjuage – ipsilateral hemisphere, contralateral pontine)

– Doll’as eyes (oculocephalic reflex) afferent 8, efferent 3,6

– Oculovestibular (COWS, caloric reflex)

Corneal reflex afferent V1, efferent 7

Gag reflec CN 9,10

Jaw jerk CN 7

* Reflexes – DTR, Plantar, Primative (glabellar, palmomental)

* Motor exam – spontaneous movement, symmetry, purpose, tone, power, rxn to noxious stimuli

Note: RAS or bihemispheric insult is required to lose consciousness

Abdominal exam (liver disease stigmata and occult blood loss)

  • Do a rectal exam

Respiratory exam

CVS exam

Differential Diagnosis (AEIOU TIPS)

A- alcohol, drugs, toxins

E- endocrine, exocrine(liver), electrolytes

I- insulin (diabetes)

O- oxygen, opiates

U- uremia, renal, HTN

T- trauma, temperature

I- infection (CNS, systemic)

P- psychiatric, porphyria

S- space occupying lesions, stroke, SAH, shock

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