Acute Care 29: Altered Level of Consciousness
Causes (Tips from the Vowels):
| T—Trauma, Temperature, Tumor | A—Alcohol |
| I—Infection | E—Epilepsy, Encephalopathy |
| P—Poisoning, Psychogenic | I—Insulin |
| S—Stroke, Shunts, Shocks | O—Oxygen, Opiates, and Drug Abuse |
| U—Uremia and Other Metabolic Abnormalities |
Assessment Tools
DO the DON’T
D—Dextrose
IV for possible hypoglycemia, unless a bedside glucose has been
determined to be normal. For adults and children weighing >26
kg,
give 50 mL IV bolus of 50% glucose.
PEDS: For children weighing 5
kg to
25 kg, give 2 mL/kg of 25% glucose. For infants weighing < 5 kg,
give 2 to 4 mL/kg of 10% dextrose.
Do not give dextrose to a
brain-injured patient without checking blood
glucose level first.
O—Oxygen
N—Naloxone
for possible opiate intoxication (after the patient is secure), give 1
to 2 mg IV every 2 to 3 minutes in adults. PEDS: For infants,
give 0.1
mg/kg.
(Beware of patients on chronic opioids. In such patients, titrate
Narcan for effect. Avoid acute withdrawal.)
T—Thiamine
100 mg IV push in adults; give before glucose.
Mini Neuro Exam
1. Level of Consciousness—AVPU Method
| LOC | GCS equivalent | ||
| A | Alert | 14 to 15 | |
| V | Responds to voice | 12 to 13 | |
| P | Responds to pain | 8 | |
| U | Unresponsive | 3 to 4 | |
2. Pupils and
Vision—Conjugate or disconjugate gaze?
Pupil size, equality, and reactivity
Vision check with finger counting
3. Tympanic Membranes—Hemotympanum?
4. Neck Tenderness Midline tenderness?
5. Extremities—Movement
and strength on command or pain
Withdraws, purposeful or none
Ankle, patellar and brachial reflexes and clonus
Babinski signs
Sensation and position sense
6. Trunk—Priapism, saddle sensation, anal sphincter tone, sensation level
If there is a
depressed LOC with lateralization:
Check
for dilated pupil and limb weakness on the opposite side. If present,
uncal herniation may be occurring. For adults, give mannitol 1 g/kg IV.
PEDS: In children, give 0.25
to 0.5 g/kg IV. Orotracheally intubate,
maintain ventilation rate at 10-12 breaths per minute, and complete the
initial survey. Do not hyperventilate aggressively. PCO2 > 30
may be
harmful.
If there is
seizure activity:
Either diazepam or
midazolam are acceptable pharmacological treatment
choices.
Diazepam
(Valium): In adults, administer diazepam 8 to 10 mg (IV or
rectal).
PEDS: In children, give 0.2
mg/kg IV up to 10 mg. Repeat dose in 5
minutes, if needed. Administer oxygen by mask. If patient has a
depressed gag reflex, orotracheally intubate. Prepare for vomiting,
aspiration, and cardiac arrhythmias. Complete the initial survey.
Midazolam
(Versed): In adults, administer 0.1 to 0.2 mg/kg IV or IO
to maximum of
10 mg bolus, followed by continuous infusion at rates of 0.75 to 10
μg/kg per minute. PEDS:
In infants and
children, give 0.05 to 0.1 mg/kg
IV or IO to maximum of 5 mg/kg or 0.2 to 0.5 mg/kg by buccal route to
maximum of 10 mg and or 0.1 to 0.2 mg/kg IM to maximum of 10 mg.1-3
If the patient
is posturing:
Check
for decorticate (arm flexion) or decerebrate (arm and leg extension)
posturing. If present, for adults, give 1 g/kg mannitol IV. PEDS: In
children, give 0.25 to 0.5 g/kg IV. Orotracheally
intubate, maintain
ventilation rate at 10-12 breaths per minute, and complete the initial
survey. Do not hyperventilate aggressively. PCO2 > 30 may be
harmful.
If there is
evidence of a spinal cord lesion or injury:
Look
for paralysis, sensory deficit, and priapism. A more thorough mini
neuro exam may be done later. But if RSI must be done quickly, it
should be preceded by a mini neuro exam first.
Stabilize the patient’s
neck before intubation.
References
- Tsai A, Jancik J. HCMC Pediatric Emergency Drug Book. Minneapolis, MN (in press, 2011).
- Wilfong A. Management of status epilepticus in children. UpToDate. http://www.uptodate.com/contents/management-of-status-epilepticus-in-children. Updated September 24, 2010. Accessed June 8, 2011.
- McMullan J, Sasson C, Pancioli A, Silbergleit R. Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: a meta-analysis. Acad Emerg Med. 2010;17(6):575-582.
- Stecker MM. Status epilepticus in adults. UpTo Date. http://www.uptodate.com/contents/status-epilepticus-in-adults. Updated February 2, 2011. Accessed June 8, 2011.