Altered consciousness

Question 1

Causes of altered conscious level

Answer 1

• Collapse secondary to cardiovascular disease Hypoxaemia and/or hypercarbia due to respiratory failure
• Shock due to any cause (e.g. sepsis, hypovolaemia, anaphylaxis)
• Diabetic emergencies (Diabetic ketoacidosis, hyperosmolar hyperglycaemic state, hypoglycaemia)
• Endocrine emergencies
• Hypothermia
• Hepatic encephalopathy
• Uraemic encephalopathy
• Poisoning and overdose
• Seizures and epilepsy including eclampsia
• Head injury
• Acute stroke
• Cerebral tumour or infection
• Intracranial bleeds
• Poisoning
• Alcohol or substance misuse
• Mental health conditions

Question 2

Causes of altered mental status

Answer 2

• Dyspnoea
• Head trauma: concussion, haemorrhage, stroke
• Fever
• Electrolyte abnormalities
• Infection
• Systemic disease affecting the CNS
• Primary intracranial disease
• Exogenous toxins
• Drug withdrawal states
• Psychosis

Question 3

What to do when a patient presents at the ED with altered mental status

Answer 3

• Check blood glucose!! ⚠️
• Consider giving thiamine if your’e concerned regarding nutrition
• A-E
• Consider giving naloxone in opioid overdose

Question 4

Important to include when taking a hx from a patient regarding altered mental status

Answer 4

It may be impossible to take the hx from the patient, possible that a collateral will be the only source of information

• Any new medication?
• Any substance use?
• Time course of altered mental status
• Associated symptoms

Question 5

What is AVPU?

Answer 5

Scale used to rapidly grade a patient’s gross level of consciousness

A: Alert: aware of examiner and can respond to the environment, follow commands, open their eyes and track objects

V: Verbal response: patients eyes do not open spontaneously, only in response to verbal stimuli directed towards them. Patient able to react to verbal stimuli in direct and meaningful way

P: Painfully responsive: patient’s eyes do not open spontaneously, only to the application of a painful stimuli e.g. move, moan or cry when pain is applied

U: Unresponsive: patient does not respond spontaneously, to verbal commands or to pain

Question 6

What is GCS?

Answer 6

Glasgow Coma Scale

Used to objectively describe the extent of impaired consciousness

• Can be used in those 5yrs+ (younger children cannot provide necessary verbal response or obey motor commands

Score from 3-15 based on eye response, verbal response and motor response

Question 7

Downsides to GCS and AVPU

Answer 7

AVPU is significantly less accurate when predicting mortality when compared to GCS

GCS: language barrier, intellectual or neurological deficit can skew results, hearing loss or speech impediment, intubation, sedation