Assessing Consciousness

AVPU and Glasgow Coma Scale

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.


Rapid Assessment
A Alert
V responds to Voice
P responds to Pain
U Unresponsive
Glasgow Coma Scale
Assesses patients neurological condition

Value range 3 to 15

3 totally comatose patient

15 fully alert patient
Classification of Brain Injury
According to Glasgow Coma Scale
(GCS) (HICKEY 2003)
MILD
GCS 13-15
MODERATE
GCS 9-12
SEVERE
GCS 3-8
Neurological chart
GCS top section

Temperature/BP/pulse/respiratory rate

Pupil size / reaction to light

Limb movement arms and legs
Eye opening
Spontaneous = 4

To speech = 3

To pain = 2

None = 1
Verbal response
Orientated = 5

Disorientated = 4

Monosyllabic = 3

Incomprehensive = 2

None = 1
Motor response
Obeys commands = 6

Localises pain = 5

Withdrawal to pain = 4

Flexion to pain = 3

Extension to pain = 2

None = 1
Posturing
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.
Signs of ???
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


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?
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

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

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

Late Signs & Symptoms of
Raised ICP
Continued deterioration in level of
consciousness

Hemiplegia, decortication &
decerebration

Alteration in vital signs


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.
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
References

Critical care education group, SUHT Oct 2004

Hickey. J. (2003) 5
th
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


Common causes of a
decreased conscious level.
Intracranial haemorrhage
Cerebral infarction
Intracranial infection
Hypothermia
Hyperthermia
Hypothyroidism
Hepatic encephalopathy
3 parameters
Eye opening
Verbal response
Motor response


Problems of decreased
conscious levels
Inability to protect airway loss of cough
and gag reflexes

Increased risk of aspiration

Skin damage

Corneal ulceration