Introduction

u Normal consciousness includes an awareness of self and surroundings

u Consciousness requires for the following to be intact:
u Reticular activating system (RAS), located mostly within in the brainstem
controls sleep-wake cycles
u At least one of the cerebral hemispheres

Impaired consciousness u Damage to one or more of these structures can result in impaired
consciousness
u E.g. damage to brainstem with intact cerebral hemispheres can lead to the
vegetative state with sleep-wake cycles but inability to process information

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Clinical assessment Clinical assessment (continued)

u Level assessed formally in the D part of ABCDE using AVPU or

Glasgow Coma Scale (GCS)
Motor response None
u Pupils
u AVPU scale (most reliable) Extension (decerebrate)
u Size normally 3-7mm

u Symmetry
u Alert fully awake Abnormal flexion (decorticate)
u Voice only responsive to voice Localises to central painful stimulus u Reactivity to light
u Pain only responsive to a painful stimulus (e.g. supraorbital Withdraws from peripheral painful stimulus
pressure) [approximately equal to GCS 8] Obeys commands
u Motor examination may not be possible, but should be able to evaluate
u Unresponsive patient is unresponsive symmetry of tone for example, even in deep coma
Verbal None
u Glasgow coma scale (see table)
response Incomprehensible sounds
u Reflexes
u Gold standard tool u Emphasis on symmetry
Inappropriate words
u Score ranges from 3 to 15 Confused u Plantar response is most important to document
u Important to record best response Orientated
u Tips: central painful stimulus supraorbital pressure or trapezius u Blood glucose
squeese (NOT sternal rub !); peripheral painful stimulus Eye opening None
nailbed pressure To pain
To voice
Spontaneous

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Differential diagnosis (non-neurological) Differential diagnosis (non-neurological)

Pupils Motor exam Plantars Blood glucose Other Pupils Motor exam Plantars Blood glucose Other
Encephalitis PERL Focal deficits Up-going Unaffected Fever, seizures, cold-sores (herpes Hypoglycaemia PERL Nill Downgoing/neutral Low Hx of diabetes,
virus), meningism insulin use
Raised intracranial Asymmetry +/- Focal deficits Up-going Unaffected Cushings response bradycardia Shock PERL Nill Downgoing/neutral Unaffected Haemodynamic
pressure delayed or non and hypertension; sudden severe instability
haemorrhage, reactive headache
Opiate overdose Constricted Nill Downgoing/neutral Unaffected Low respiratory rate
tumour or
hydrocephalus Other drugs/toxins Variable Nill Downgoing/neutral Unaffected Hx of substance
misuse, new
Epilepsy non- Dilated (during Temporary deficits Up-going (if Unaffected Observed tonic-clonic prescription
convulsive status seizure) history of movements, history of epilepsy Metabolic PERL Nill Downgoing/neutral Unaffected Liver/renal failure,
epilepticus, post- neurological encephalopathy fluctuating
ictal state brain injury) consciousness
Concussion Normal unless Normal unless Normal unless Unaffected History of head injury CO2 narcosis PERL Nill Downgoing/neutral Unaffected History of COPD with
bleed causing bleed causing bleed causing T2RF, above target
raised ICP raised ICP raised ICP sats, hypercapnia

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Workup Principles of management neurological causes

u Full ABCDE assesssment u Encephalitis

u GCS 8 = patient cannot maintain airway and needs intubation u IV aciclovir
u Bloods FBC, U&E, LFTs, glucose; arterial blood gas u Raised intracranial pressure
u Drug screen u Head incline, minimal neck pressure
u Check inpatient drug charts opiates, night time sedatives of importance u Seek specialist neurosurgical advice may need IV mannitol
u Urinary tox-screen
u Seizure related
u CT head u If suspecting non-convulsive status IV phenytoin infusion
u If neurological cause suspected u Post-ictal monitor closely
u Other investigations - lumbar puncture if suspected subarachnoid haemorrhage /
encephalitis; electroencephalogram if suspecting non-convulsive status epilepticus

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Principles of management neurological causes Additional resources

u Hypoglycaemia u Neurology & Neurosurgery illustrated

u If conscious lucozade /glucogel
u If unconscious IV high concentration glucose, consider IM glucagon u Oxford handbook of clinical medicine 9th edition
u If patient is unknown/malnourished/hx of alcohol abuse always give IV thiamine (Pabrinex) before giving
glucose to prevent precipitating wernickes encephalopathy

u Suspected opiate overdose

u Reversal with naloxone

u Suspected benzodiazepine overdose

u Reversal with flumazenil

u Metabolic encephalopathy
u Specialist advice may need dialysis (renal failure) or lactulose (liver failure)

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