Assessing Consciousness

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Assessing Consciousness

• AVPU and Glasgow Coma Scale

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Lesson objectives

• Describe the common causes of a deteriorating
  conscious level.
• Describe how to assess a patient with a altered
  conscious level using the Glasgow coma scale.
• Describe the emergency management of a patient
  with a decreasing conscious level.

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Rapid Assessment

• A Alert
• V responds to Voice
• P responds to Pain
• U Unresponsive
  

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Glasgow Coma Scale

• Assesses patients neurological condition
• Value range 3 to 15
• 3 totally comatose patient
• 15 fully alert patient

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Classification of Brain InjuryAccording to
Glasgow Coma Scale(GCS)
(HICKEY 2003)
SEVERE GCS 3-8
MODERATE GCS 9-12
MILD GCS 13-15
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Neurological chart

• GCS top section
• Temperature/BP/pulse/respiratory rate
• Pupil size / reaction to light
• Limb movement arms and legs

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Eye opening

• Spontaneous 4
• To speech 3
• To pain 2
• None 1

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Verbal response

• Orientated 5
• Disorientated 4
• Monosyllabic 3
• Incomprehensive 2
• None 1

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Motor response

• Obeys commands 6
• Localises pain 5
• Withdrawal to pain 4
• Flexion to pain 3
• Extension to pain 2
• None 1

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Posturing
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Case 1

• 20 year old brought in by ambulance on
  stretcher/spinal board.
• Fell down flight of stairs in night club.
• Head injury/laceration scalp.
• Loss of consciousness(LOC) approx10-15 mins.
• Not speaking but groaning to pain stimuli.
• Eyes open to pain stimuli.
• When squeeze fingernail attempts to flex arm away
  from pain.

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Signs of ???
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Signs of basal skull fracture

• Blood or CSF from nose or ear
• Periorbital haematoma
• Mastoid haematoma (Battle's sign)
• Haemotympanum
• Radiological evidence
  of intra-cranial air
• Radiological evidence
  of fluid levels in
  sinuses

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Case 2

• 66 year old brought in by ambulance and police.
• Sat in a wheelchair.
• Found in city centre staggering and unsteady on
  his feet.
• He collapsed whilst with police.
• No known injuries.
• No loss of consciousness.
• Talking to you, confused answers to questions.
  Eyes open, obeys commands.
• What could be going on with this patient?

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Causes of a decreased conscious level

• Hypoxaemia
• Hypotension
• Hypercapnia
• Hypoglycaemia
• Drugs (sedatives,opiates,
• overdoses,alcohol)
• Seizures
• Head injury

• Intracranial haemorrhage
• Cerebral infarction
• Intracranial infection
• Hypothermia
• Hyperthermia
• Hypothyroidism
• Hepatic encephalopathy

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Early Signs Symptoms of Raised ICP

• Deterioration in level of consciousness (LOC)
• Confusion
• Restlessness
• Lethargy
• Headache
• Pupillary dysfunction
• Motor sensory deficits
• Cranial nerve palsy

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Transient Signs Symptoms of Raised ICP

• Decreased LOC
• Pupil abnormalities
• Visual disturbance
• Motor dysfunction
• Headache vomiting
• Aphasia
• Changes in respiratory pattern
• Changes in vital signs

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Late Signs Symptoms of Raised ICP

• Continued deterioration in level of consciousness
• Hemiplegia, decortication decerebration
• Alteration in vital signs

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Raised ICP Management of Deteriorating
Conscious Level

• Ensure the patients airway is patent
• Give high concentration oxygen to ensure good
  cerebral profusion
• If ventilation is inadequate, provide assisted
  ventilation.
• Ensure intravenous access and prescribe fluids as
  necessary
• Reverse any drug induced CNS depression.
• Measure the blood glucose and treat if level is
  below 3mmol/l.
• Place patient horizontally in the left lateral
  recovery position.

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Summary

• A decreased level of consciousness is common in
  acute illness
• Hypoxaemia,hypotension, hypoglycaemia are common
  causes of coma
• A decreased consciousness level may cause airway
  obstruction and loss of protective airway
  reflexes
• Failure to identify early signs and symptoms of
  raised intracranial pressure puts the patient at
  great risk, and opportunity for intervention may
  be lost
• Potential if untreated a respiratory or cardiac
  arrest
• Treatment of a deteriorating consciousness is
  focused on care of the airway, breathing,
  circulation disability and exposure

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References

• Critical care education group, SUHT Oct 2004
• Hickey. J. (2003) 5th Ed The Clinical Practice of
  Neurological and Neurosurgical Nursing
• Intranet Marsden Manual. Neurological
  observation
• Mooney G (2003) Neurological observations.
  Nursing times Vol 99/ No 17
• Smith G (2003) Alert manual. University of
  Portsmouth

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Common causes of a decreased conscious level.

• Intracranial haemorrhage
• Cerebral infarction
• Intracranial infection
• Hypothermia
• Hyperthermia
• Hypothyroidism
• Hepatic encephalopathy

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3 parameters

• Eye opening
• Verbal response
• Motor response

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Problems of decreased conscious levels

• Inability to protect airway loss of cough
• and gag reflexes
• Increased risk of aspiration
• Skin damage
• Corneal ulceration