APPROACH TO ALTERED

CONSCIOUSNESS
Dr. Sujeeta Bajracharya
Assist. Prof. Dept. Of General Practice &
Emergency Medicine
DEFINITION OF UNCONCIOUSNESS
absence of awareness and responsiveness to

surroundings

Two process of disorder of consciousness

disorder of arousal
disorder of content of consciousness
 Arousal behavior include wakefulness and basic
alerting

Content of awareness include self awareness,

language, reasoning, spatial relationship,
emotion, integration process that make a human
OTHER DEFINITIONS

Delirium
Dysfunction of both arousal system and content of
consciousness

Dementia
Failure of the content portion of consciousness with
relatively preserved alerting function

Coma
Failure of both arousal system and content of
consciousness
PATHOPHYSIOLOGY OF
UNCONSCIOUSNESS

reticular activating system (RAS) neurons extending from midbrain

pons and medulla

Damaged by metabolic
adisturbance or compressed
by invasive lesion

unconsciousness
 Mental status
Clinical state of emotional and intellectual
functioning of the individual

6 elements f MSE
appearance, behavior, and attitude
disorder of thought
disorder of perception
mood and affect
insight and judgment
sensorium and intelligence
1. Appearance, 4. Mood and affect
behavior, and attitude prevailing mood and
Dress emotional content
Motor behavior at rest
Speech pattern
5. Insight and judgment
understanding of the
surrounding environment
2. Disorder of thought
thoughts logical and
realistic
false belief or delusion 6. Sensorium and
suicidal or homicidal intelligence
thoughts level of consciousness
cognition or intellectual
functioning
3. Disorder of perception
hallucination
 State C/F Simplified Classification
1.Consciousness Aware and wakeful Awake

2.Clouded Reduced awareness and

consciousness wakefulness
Alcohol effect confusion
drowsiness
3.Stupor Unconscious Responds to shake and
shout
Deep sleep like state

Around with vigorous

stimuli
4.Semicomatose Unconscious (deeper) Responds to pain

Responds only to painful

stimuli (Sternal rubbing
with knuckles) wiout
arousing
5.Coma Deeply Unresponsive coma
unconsciousness
Unarousable and
unresponsive
MINI MENTAL STATE EXAMINATION
Maximum Score Questions
score
5 ( ) Orientation
What is the year, season, day, month?
5 ( ) Where we are: country, district, city, hospital, floor?
3 ( ) Registration
Name three objects, ask the patient to repeat.
5 ( ) Attention and calculation
The serial 7 test. Stop after 5 correct answer.eg Spell
world backward

3 ( ) Recall
Ask three objects named above to recall
MINI MENTAL STATE EXAMINATION
Maximum Score Questions
score

9 ( ) Language
Name a pencil and watch-2
Repeat the following(no ifs, ands, buts)-1
Follow three stage command:(take a paper
in your right hand, fold it in half, put it on
the table)-3
Read and follow the following:
Close your eyes-1
Write a sentence-1
Copy the design-1
Scoring:
Score -23 -dementia or another cognitive disorder and

suggests the need for further testing and evaluation.

GLASGOW COMA SCALE
GLASGOW COMA SCALE
Important Medical Causes of
Delirium in Adult patients

Infectious
Pneumonia
Urinary tract infection
Meningitis or encephalitis
Sepsis
Metabolic/toxic

Hypoglycemia
Alcohol ingestion
Electrolyte abnormalities
Hepatic encephalopathy
Thyroid disorders
Alcohol or drug withdrawal
Neurologic

Stroke or transient ischemic attack

Seizure or postictal state
Subarachnoid hemorrhage
Intracranial hemorrhage
Central nervous system mass lesion
Subdural hematoma
Cardiopulmonary

Congestive heart failure

Myocardial infarction
Pulmonary embolism
Hypoxia or CO2 narcosis
Drug-related

Anticholinergic drugs
Alcohol or drug withdrawal
Sedatives-hypnotics
Narcotic analgesics
Polypharmacy
CLASSIFICATION OF DEMENTIA BY
CAUSE
Degenerative
Alzheimer's disease
Huntington's disease
Parkinson's disease, others

Vascular
Multiple infarcts
Hypoperfusion (cardiac arrest, profound
hypotension, others)
Subdural hematoma

Subarachnoid hemorrhage
Infectious

Meningitis (sequelae of bacterial, fungal, or tubercular)

Neurosyphilis
Viral encephalitis (herpes, human immunodeficiency virus),
Creutzfeldt-Jakob disease
Inflammatory
Systemic lupus erythematosus
Demyelinating disease, others

Neoplastic
Primary tumors and metastatic disease
Carcinomatous meningitis
Paraneoplastic syndromes
Traumatic
Traumatic brain injury
Subdural hematoma

Toxic
Alcohol
Medications (anticholinergics, polypharmacy)
Metabolic
Vitamin B12 or folate deficiency
Thyroid disease
Uremia, others

Psychiatric
Depression (pseudodementia)

Hydrocephalic
Normal-pressure hydrocephalus (communicating
hydrocephalus)
Noncommunicating hydrocephalus
FOR GP & EM

any unconscious or altered consciousness patient

with an unknown background

always consider 2 things at first

o Hypoglycaemia

o opioid overdose
INITIAL GENERAL MANAGEMENT OF
UNCONSCIOUS PATIENT/ PRIMARY SURVEY
A. Airway and cervical spine

Assess, clear, and protect airway: jaw thrust/chin lift,

suctioning.

Perform endotracheal intubation with in-line

stabilization for patient with depressed level of
consciousness or inability to protect airway.

Create surgical airway if there is significant bleeding

or obstruction, or laryngoscopy cannot be performed.
 B. Breathing Ventilate with 100% oxygen,
monitor oxygen saturation.

Auscultate for breath sounds.

Inspect thorax and neck for deviated trachea, open

chest wounds, abnormal chest wall motion, crepitus
at neck or chest.

Consider immediate needle thoracostomy for

suspected tension pneumothorax.

Consider
tube thoracostomy for suspected
hemopneumothorax.
 C. Circulation
Assess for blood volume status: skin color, capillary refill,
radial/femoral/carotid pulse, blood pressure.

Place two large-bore peripheral IV catheters.

Begin rapid infusion of warm crystalloid solution, if indicated.

Apply direct pressure to sites of brisk external bleeding.

Consider central venous access if peripheral sites are unavailable.

Consider pericardiocentesis for suspected pericardial tamponade.

Consider left lateral decubitus position in late-trimester pregnancy.

 D. Disability

Performscreening neurologic and mental status

examination, assessing:

Pupil size and reactivity

Limb strength and movement, grip strength

Orientation, Glasgow Coma Scale score

Consider measurement of capillary blood glucose level in

patients with altered mental status.
 E. Exposure

Completely disrobe the patient, inspect for burns,

toxic exposures.

Log-roll patient, maintaining neutral position and in-

line neck stabilization, to inspect and palpate
thoracic spine, flank, back, and buttocks.
 Secondary Survey (Head-to-toe examination
for rapid identification and control of
injuries or potential instability)

Identifyand control scalp wound bleeding with direct

pressure, sutures, or surgical clips.

Identify facial instability, potential for airway

instability.

Identify hemotympanum.

Identify
epistaxis or septal hematoma; consider
tamponade or airway control if bleeding is profuse.
 Identify avulsed teeth, jaw instability.

Evaluate for abdominal distention and tenderness.

Identify penetrating chest, back, flank, or abdominal

injuries.

Assess pelvic stability, consider pelvic wrap or sling.

Inspect perineum for laceration or hematoma.

 Inspect urethral meatus for blood.

Consider rectal examination for sphincter tone and

gross blood.

Assess peripheral pulses for vascular compromise.

Identifyextremity deformities and immobilize open

and closed fractures and dislocations.
History- from relatives, friend, witnesses
ambulance officers

Setting in which patient found.

H/O onsets of illness
Evidence of drug overdose/suicide attempt
H/O suggestive of trauma
Past medical history
known case of HTN, heart disease, respiratory disease or
pshychiatric illness?
H/O Medication
H/O Allergies
Examination
General examination

General appearance

vital signs

JALCCO

Dehydration

JVP

Systemic examination
CVS-

RS-

GIS-

CNS-

Mental status examination

o GCS/level of consciousness

o AVPU
Regional examination
Head to toe

Investigation
1. blood
all patients- BS, urea, electrolytes
selected patients-FBE,ABG, LFT, blood, alcohol serum cortisol,
thyroid function test, serum digoxin.
2. Urine
glucose, albumin, drug screening

3. stomach contents-aspiration of stomach content for analysis

4. radiology- CT scan
MRI
or x-ray of skull
5. CSF-meningitis, subarachnoid haemorrhage
6. EEG
7. ECG-
Coma cocktail(TONG) is given

T-thiamine 100mg I/m or I/v 100mg I/m or I/v

O- oxygenation
N- naloxone 0.1-0.2mg I/V
G- glucose 50ml,50% dextrose

Note-
take blood for investigation before giving glucose-BSR

measurement by glucometer
use nasogastric tube to prevent acute gastric dilatation
Take home message
BASIC MANAGEMENT ESSENTIALS
1. keep patient alive(maintain airway and circulation)
2. get history from witness
3. examine patient
4. take blood for investigations
5. give coma cocktails(tong)
6. CT scan ( if diagnosis doubtful)

Secondary Survey
. detailed approach to ABCD.
. examination from head to toe.

. Management of specific causes

. Hypoglycaemia
Supportive and symptomatic treatment
I. If mental status severely depressed-insert ET tube
before gastric aspiration, if patient presents < 1 hr after
ingestion
II. hemodialysis for life threatening overdoses
III. thiamine 100ms I/V + 50ml/50%D or water I/V

IV. Admit if significant alcoholic ketoaciodosis or if

ventilator support required
V. observe until patients blood alcohol level <100mg
VI. if patients mental status more abnormal than would be
expected for blood alcohol level consider additional
toxicology testing and head CT.