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)

How to Write a Note in the ED, and How to Present your Case.

Note Format:

em-note-format

HPI: use OPQRST or OLDCARTS to organize your questions, or the approach recommended per the CC, as described in other posts .

How to Present Your Case:

Work through the structure of your note. If you always stick to the same format of the note, you will learn a mental picture that you can use as a format for your presentation.

em-note-format-numbered-for-presentation

1.,2.) ID +CC: “Here is a __ y/o Male/Female, with chief complaint of __.

3. PmHx: “List of pertinent PmHX, (ie. patient is 14 wks pregnant).”

4. Meds: if appropriate to complaint. (ie. antihypertensive meds for gestational HTN.

5. HPI: This is where things get interesting, but only after you set the stage with the above steps 1 through 4. Do not start this presentation until you have a DDX, make a mental list of:

  • Diagnoses you must exclude (can’t miss) given this CC.
  • Dx that are common for this CC.
  • A more thorough DDX can be obtained by the following mnemonics (most useful when you are starting to learn EM):
VITAMINC&D: STIMPVD:
V Vascular S Structural
I Infectious T Trauma/Toxin
T Trauma/Toxin I Infectious/Iatrogenic/Ingestion
A Acquired M Metabolic/Endocrine
M Metabolic P Pregnancy/Psych
I Iatrogenic V Vascular
N Neoplastic D Drugs/Meds
C Congenital
D Degenerative
E Endocrine

Organize your Symptoms according to your DDX:

(This is key to keep your preceptor interested, if it is not organized, their attention will drift off)

This is likely the most cognitively challenging part of the case presentation. You will need to focus on one Dx at a time, and recall the symptoms that support/refute the proposed Dx. Then move onto the next Dx.

6. On Exam (O/E):

  • Force yourself to copy the vitals in your note, this forces you review them, (check for SIRS Criteria, or qSOFA).
  • Organize these findings according to DDX as well.

7. Labs Values, or Prior Investigations:

8. Your Assessment/Plan:

  • Symptom Relief you recommend.
  • Differential Diagnosis.
  • Investigations.
  • Treatment options, according to results of investigation.
  • Disposition: admission vs going home vs followup care.