1. Assessing Consciousness
AVPU and Glasgow Coma Scale

2. 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.

3. Rapid Assessment
A Alert
V responds to Voice
P responds to Pain
U Unresponsive

4. Glasgow Coma Scale Assesses patient’s neurological condition
Value range 3 to 15
3 totally comatose patient
15 fully alert patient

5. Classification of Brain Injury According to Glasgow Coma Scale (GCS) (HICKEY 2003)
SEVERE
GCS 3-8
MODERATE
GCS 9-12
MILD
GCS 13-15

6. Neurological chart GCS top section
Temperature/BP/pulse/respiratory rate
Pupil size / reaction to light
Limb movement – arms and legs
9 OR BELOW CAUSE FOR ALARM
PUPIL SIZE AND REACTIVITY 3RD CRANIAL NERVE CONTROLS THE PUPILS ABILITY TO CONSTRICT INJURY TO BRAIN INCREASES PRESSURE COMPRESSES NERVE
LIGHT SHONE DIRECTLY INTO ONE EYE CAUSING IT TO CONSTRCT CALLED DIRECT LIGHT REFLEX THIS CAUSES THE OTHER EYE TO CONSTRICT CALLED CONSESUAL REFLEX IF PUPILS ARE EFFECTED THIS IS A ALTE SIGN OF INCREASING PRESSURE IN SKULL.

7. Eye opening
Spontaneous = 4
To speech = 3
To pain = 2
None = 1

8. Verbal response Orientated = 5 Disorientated = 4 Monosyllabic = 3
Incomprehensive = 2
None = 1

9. Motor response Obeys commands = 6 Localises pain = 5
Withdrawal to pain = 4
Flexion to pain = 3
Extension to pain = 2
None = 1

10. Posturing

11. 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.
GCS IS 9 CAUSE OF ALARM
ABCDE

12. Signs of ???

13. 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

14. 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?
NEVER ASSUME ANYTHING
ABCDE PMH? DIABETIC? LOOK FOR MEDIC ALERT TAGS, FALL AT HOME POLICE ARE NOT AWARE OF INTRACRANIAL BLEED, CVA , DRUNK?

16. 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

17. Early Signs & Symptoms of Raised ICP
Deterioration in level of consciousness (LOC)
Confusion
Restlessness
Lethargy
Headache
Pupillary dysfunction
Motor & sensory deficits
Cranial nerve palsy

18. 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

19. Late Signs & Symptoms of Raised ICP
Continued deterioration in level of consciousness
Hemiplegia, decortication & decerebration
Alteration in vital signs

20. Raised ICP Management of Deteriorating Conscious Level
Ensure the patient’s 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.
½ LIFE OF REVERSAL DRUGS SUCH AS NAXALONE

21. 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

22. 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

23. Common causes of a decreased conscious level.
Intracranial haemorrhage
Cerebral infarction
Intracranial infection
Hypothermia
Hyperthermia
Hypothyroidism
Hepatic encephalopathy

24. 3 parameters
Eye opening
Verbal response
Motor response

25. Problems of decreased conscious levels
Inability to protect airway – loss of cough
and gag reflexes
Increased risk of aspiration
Skin damage
Corneal ulceration