Altered Level of Consciousness (ALOC)

Taking a History from a patient with ALOC is inherently challenging, so it is important to: 1. Assess stability, 2. Immediate treatments, 3. Perform initial investigations to pair down the differential diagnosis:

  1. Stability?
    • ABC’s
    • Vitals
    • GCS
  2.  Immediate Treatments?
    • Is Intubation Necessary?
    • Opioid overdose? (Naloxone 0.4mg IM repeated 2-3 min until response. Half life approx 30min).
    • Alcohol intoxication? (need to treat for complication of Wernicke’s Encephalopathy: 100mg thiamine)
  3. Initial Investigations (Mandatory Investigations):
    • Glucose (finger stick)
    • ECG
    • Pregnancy test (BetaHCG urine), all females.
    • VBG (for suspected respiratory, or metabolic causes

DDX checklist for ALOC:
“AEIOU TIPS”
Alcohol ()
Endocrine/Electrolytes ()
Ischemia
Opiates/Oxygen (Respiratory including CO2, CO)
Uremia
Trauma
Infection (UTI, Pneumonia, Encephalitis)
Insulin
Poisoning
Seizure

On Exam (things to look for):

  • Trauma: signs of basal skull fracture (battle sign, hemotympanum),
  • Toxidrome: (skin, pupils, vitals)
    • Opioid: Hypotension, bradycardia, respiratory depression.
  • Neuro Exam
  • Facial droop
  • Resolving confusion
  • Active seizure
  • Signs of infection (SIRS criteria, qSOFA).

Additional Investigations (what are they good for?):

  • ECG (Signs of Ischemia? Dysrhythmia? Hypo/Hyperkalemia? TCA toxicity?)
  • BetaHCG (Ruptured Ectopic?)
  • Alcohol level
  • Liver Enzymes (Hepatic encephalopathy)
  • Thyroid TSH (hypothyroid)
  • Troponin (ischemia)
  • Creatinine and electrolytes (uraemia)
  • Imaging (CT) (head trauma)
  • Urine catheter urine dip (Urinary Tract Infection)
  • Portable XR (Pneumonia)
  • Lumbar puncture (Encephalitis)

Communicating a Mental Status with Others – Glasgow Coma Scale

There is no way around Memorizing this list:

Components: Eyes, Mouth, Motor with a score out of 4, 5, 6 respectively.

  1. Eyes: what when do they open?
    • open spontaneously (4),
    • open to voice (3),
    • open to pain (2)
    • no response (1)
  2. Voice:
    • pt. knows: Month and year (5)
    • any month and year (4)
    • any words (3)
    • sounds only (2)
    • no response (1)
  3. Motor:
    • Follows commands (6)
    • Localizes to pain (5)
    • Withdraws from pain (4)
    • Flexion (decorticate posturing) (3)
    • Extension (decerebrate posturing) (2)
    • no response (1)

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