Altered level of consciousness

Question 1

What is altered mental state

Answer 1

Disorders of mental functioning: from confusion to coma

Question 2

What is mental status

Answer 2

1. Level of consciousness, attentiveness

2. Cognition, mental processes or thoughts

Question 3

Confusion

Answer 3

1. Disoriented, bewildered, having difficulty following commands

Question 4

Somnolent

Answer 4

1. Sleepy, responds with only incoherent mumbles/disorganised movements

Question 5

Obtunded

Answer 5

1. Lessened interest in environment, slow response to stimulation

Question 6

Stuporous

Answer 6

1. Profoundly reduced alertness, continuous noxious stimuli required for arousal

Question 7

Comatose

Answer 7

1. State of seep, unarousable, sustained unconsciousness

Question 8

Urgent considerations/differentials

Answer 8

1. Acute neurological event: TIA/stroke, THI, IC bleed, seizures, meningitis/encephalitis, abscess, encephalopathy, delirium
2. Severe systemic infection
3. GIT: surgical abdomen
4. Cardiac: MI, CCF, arrythmias
5. Psychiatric
6. Respiratory: hypoxia, asthma, COPD, PE, pneumonia, respiratory depression, drowning
7. Medication
8. Toxidromes/drugs: alcohol, sedatives, PCP
9. Endocrine: myxedema, Addison’s
10. Metabolic: sodium, potassium, calcium
11. GLUCOSE

Question 9

Management

Answer 9

1. Basic life support: ABCDEFG
Oxygen
IV access
Vitals
2. History
Previous cognition
Functional status
Medication
Comorbid
Pain
Alcohol and drug use
Non-specific irritability
Environmental
3. Physical examination
4. Preliminary investigations:
Glucose, FBC, UEC, TFTs, Urinalysis 
CXR
Drug screen/drug levels if n digoxin, lithium, quinidine
ECG + troponins
ABG
LFTs
Cultures if suspect, ?LP (neck stiff, rigid)
Pelvic imaging if suspect hip fracture
Consider other investigations if appropriate: CT/MRI
5. Admit if appropriate

Question 10

4 cardinal signs of delirium

Answer 10

1. Acute and fluctuating
2. Inattention
3. Disorganised thinking
4. ALOC

Question 11

Diagnosis and management ALOC and smelling of alcohol

Answer 11

1. Hypoglycemia
Check glucose
Thiamine 
Glucose
2. Head injury
Extra/subdural hematoma
Neurological obs, CT
3. Other general medical conditions
Seizure, acute poisening, meningitis/infection, CVA, trauma, hypothermia
4. Acute in chronic alcoholics
Pneumonia
Cardiac
GIT hemorrhage, encephalopathy
Pancreatitis
HypoK, hypoMg, hypoCa
Wildrawal/delirium tremens
Ketoacidosis
Acidic acidosis
Renal failure
Wernickes

Question 12

Management in unconscious patient

Answer 12

1. ABCDEFG, cardiorespiratory resus if required
   Clear obstruction
   Airway patent->chin lift, jaw thrust, OPA…
   Cardiac monitoring
2. Include C-spine stabilisation if any suggestion of face, head or neck trauma
3. Remove clothing, prevent heat loss
4. IV cannula + bloods
   FBC, coags, UEC, blood glucose, ELFTs, culture/drug screen
   ABGs
5. 50ml of 50% dextrose if hypoG
6. Vitals + temp
7. Consider naloxone, flumazenil, glucose, thiamine
8. Consider critical conditions
   Tension pneumothorax: intercostal
   Cardiac arrythmia: ECG and treat
   Exsanguination: cross match + fluids + USS
   Anaphylaxis: Remove allergen + lay flat + Adrenalin 0.5 ml (0.5mg) adult IM
   Extradural hemorrhage: airway + CT + neurosurg
9. NGT
10. Catheter

Question 13

Most common causes of unconscious

Answer 13

1. Poisening
2. Hypoglycemia
3. Post-ictal
4. Stroke
5. Head injury
6. SAH
7. Respiratory failure
8. Hypotension/shock

Question 14

Less common causes of unconscious

Answer 14

1. Meningitis/encephalitis
2. Hepatic or renal failure
3. Septicemia
4. Subdural