This Powerpoint Presentation will help to understand the concept of Altered Level of Consciousness.

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Altered level of
Consciousness
Ms Tarika Sharma
Assistant Professor
MMCON, MMU

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 The level of responsiveness and consciousness
is the most important indicator of the patient’s
condition.
 Consciousness is defined as being awake and
aware of both one’s self and one’s
surroundings, OR it is the human awareness
of both internal and external stimuli.
Introduction

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Altered Consciousness covers a spectrum of states:
Consciousness
Lethargy
Stupor or Obtunded
Coma
Continuum
Introduction
Consciousness Coma

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Lethargy: Mild depression in level of consciousness
and can be aroused with little difficulty.
Obtund : More depressed level of consciousness and
can not be fully aroused.( slow response and
sleepiness)
Stupor : Can not be aroused from a sleep like state.
(only respond by painful stimuli)
Coma: More depressed level of consciousness and
unable to make any purposeful response.
Introduction

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Coma
 Derived from the Greek word ‘Koma’ or deep sleep
 Coma is a clinical state of unconsciousness in which
the patient is unaware of self or the environment for
prolonged periods (days to months or even years).
 It is an alteration of consciousness in which a person
appears to be asleep, cannot be aroused even by
painful stimuli, and shows no awareness of the
environment.

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Akinetic mutism
 It is a state of unresponsiveness to the
environment in which the patient makes no
movement or sound but sometimes opens the
eyes.

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Persistent vegetative
state
Is a condition in which the patient is
described as wakeful but devoid of conscious
content, without cognitive or affective mental
function.

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 Inability to move or respond except for eye
movements due to a lesion affecting the pons.
Locked In Syndrome

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Cranial Causes:
Structural
 CNS infections
 Mass lesions  CSF obstruction + ↑ volume
 Trauma
Functional
 Seizures
 Hypoxic - ischemic injury
Etiology

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Etiology
 Systemic shock
 hypo/ hypernatremia
 hypoglycemia
 diabetic coma
 hepatic
 uremic
 hypoxia
 Respiratory failure
 Acidosis/ alkalosis
Extracranial causes
Metabolic

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Etiology
 Barbiturates
 benzodiazepines
 Opioids
 antihistamines
 Iron
 Salicylates
Extracranial causes
Drugs

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Etiology
 Lead
 CO poisoning
 pesticides
 alcohol/
ethylene glycol
Extracranial causes
Toxic

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Etiology
Endocrine
 hypothyroidism
 diabetes
Miscellaneous
 hypertensive encephalopathy
 heat stroke
 hypothermia
Extracranial causes

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 Normal consciousness is maintained by integrity of certain
areas of the cerebral cortex, thalamus and brain stem
 Altered consciousness due to:
Diffuse insult to both cerebral hemispheres
(metabolic/toxic/hypoxic/ischemic)
or
focal lesion affecting ascending reticular activating system
(ARAS) located in upper pons, midbrain & diencephalon.
Affected by compression (herniation)
Pathophysiology

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Pathophysiology
Underlying cause
Disruption in the cells of the nervous system,
neurotransmitters, or brain anatomy.
Results in faulty impulse transmission, impeding
communication within the brain or from the brain to
other parts of the body.

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The level of responsiveness and consciousness is the
most important indicator of the patient’s condition.
 Level I-conscious, cognitive, coherent (3 C’s)
 Level II-confused, drowsy, lethargic, obtunded,
somnolent
 Level III-stuporous;responds only to noxious, strong or
intense stimuli, e.g sternal pressure, trapezius pinch,
pressure at the base of the nail or supraorbital area;very
strong light or very loud sound.
Level of Consciousness

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 Level IV
=Light coma-response is only by grimace or
withdrawing limb from pain; primitive and
disorganized response to painful stimuli.
=Deep coma-absence of response to even the most
painful stimuli.
Level of Consciousness…

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 Circumstances?
 Duration & onset? Acute in CNS infection, trauma,
seizure, poisoning, metabolic, vascular
 H/o poisoning?
 H/o trauma?
 H/o fever?
 H/o seizure?
 Past medical history
 H/o seizures in the past?
 H/o known endocrine disorder?
 H/o headache/vomiting/visual symptoms?
Quick History & Examn

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 Vitals
 Fever
 BP
 S/o shock
 S/o ↑ ICP bradycardia, hypertension
 Respiration  rapid in acidosis & CNS lesions also
 General Physical:
 Evidence of trauma, injury, tongue bite
 Jaundice
 Breath - for odor of ketones, fetor hepaticus etc
 Skin peticheae, exanthem
 Moist skin with ↑salivation in organophosphorus
poisoning
 Complete systemic exam
Quick History & Examn

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 The goal of neurologic examination are:
 To determine depth of coma.
 To localize the process leading to coma.
 Includes
 Level of consciousness (Glasgow coma scale)
 Pupillary responses
 Eye movements(spontaneous or induced)
 Motor response
 Meningeal signs
 Sign of increased ICP
Neurological Examn

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ACTIVITYACTIVITY
BEST RESPONSEBEST RESPONSE
Adults/Older ChildrenAdults/Older Children Infants ( modified GCS )Infants ( modified GCS ) ScoreScore
Eye OpeningEye Opening
( E )( E )
1.1. SpontaneousSpontaneous
2.2. To speechTo speech
3.3. To painTo pain
4.4. NoneNone
1.1. SpontaneousSpontaneous
2.2. To speechTo speech
3.3. To painTo pain
4.4. NoneNone
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VerbalVerbal
( V )( V )
1.1. Appropriate speechAppropriate speech
2.2. Confused speechConfused speech
3.3. Inappropriate wordsInappropriate words
4.4. Incomprehensible orIncomprehensible or
none specific soundsnone specific sounds
5.5. NoneNone
1.1. Coos, babblesCoos, babbles
2.2. Irritable, cries butIrritable, cries but
consolableconsolable
3.3. Cries, inconsolableCries, inconsolable
4.4. Moans to painMoans to pain
5.5. NoneNone
55
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MotorMotor
( M )( M )
1.1.Obeys commandsObeys commands
2.2.Localizes painLocalizes pain
3.3.Withdraws to painWithdraws to pain
4.4.Decorticate to painDecorticate to pain
5.5.Decerebrate to painDecerebrate to pain
6.6.NoneNone
1.1. Normal spontaneousNormal spontaneous
movementmovement
2.2. Withdraws to touchWithdraws to touch
3.3. Withdraws to painWithdraws to pain
4.4. Decorticate to painDecorticate to pain
5.5. Decerebrate to painDecerebrate to pain
6.6. NoneNone
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Glasgow coma scale

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Size and reactivity of pupils
Pupils Lesion/Dysfunction
Pinpoint Pons, opiates, cholinergic intoxication
Mid position –
fixed or irregular
Midbrain lesion
Unilateral ,
dilated and fixed
Uncal herniation
Bilateral , dilated
and fixed
Diffuse damage, central herniation,
global hypoxia ischemia, barbiturates,
atropine

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Eye movements

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Motor response

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Meningeal signs

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 The signs of raised ICP includes:
1- abnormal respiratory pattern.
2- unequal or unreactive pupils.
3-impaired or absent oculocephalic or
oculovestibular responsees.
4- systemic hypertension, bradycardia.
5- tense fontanelle.
6- abnormal body posture or muscle flaccidity.
S/o ↑ICP

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 Blood:
CBC, clotting and bleeding time
Glucose, electrolyte, urea, liver function test,
ammonia, and lactate
 Toxocology:
Urine, blood,gastric aspirate for ingestion
 Acid-base:
ABG
Investigations

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 Microbiology:
Blood and urine cultures
 Imaging:
CT , MRI
 Lumbar puncture – CI if ↑ICP. Abnormal in CNS
infections
Investigations

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 Coma is an acute life-threatening neurological
emergency
 Requires prompt intervention for preservation of
life & brain function
 So the ABC are the initial priority
Immediate Management

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 A – airway  prevent tongue falling back, suction
 B – breathingrespiratory support, oxygen
 C- circulationiv fluids, monitor BP, vasopressors
 If any evidence of poisoning  GL
Immediate Management

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 ABCs:
 Intubate if GCS ≤8 or respiratory failure
 Stabilize cervical spine
 Supplement O2
 IV access
 Blood pressure support as needed
 Dextrose 0.25 g/kg (2.5 mL/kg of 10 % dextrose
solution)
 Treat definite seizures. Lorazepam (0.1 mg/kg,
maximum single dose 5 mg). If seizures continue
treat as for status epilepticus.
Treatment

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 Infection:
 Ceftriaxone 100 mg/kg (maximum single dose 2
grams) and Vancomycin
 Acyclovir
 Ingestion:
 Naloxone 0.1 mg/kg IV; maximum 2 mg IV (use if
opioid toxidrome: miosis, respiratory depression,
hypotonia)
 Increased ICP:
 Mannitol 0.5 - 1 gram/kg IV
Treatment

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Complications
 Respiratory failure
 Pneumonia
 Pressure ulcers, and
 Aspiration.

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 Check LOC of patient using GCS.
 Determining the patient’s orientation to time, person, and
place assesses verbal response.
 The patient is asked to identify the day, date, or season of
the year and to identify where he or she is or to identify
the clinicians, family members, or visitors present.
 Other questions such as, “Who is the president?” or
“What is the next holiday?”
Nursing Assessment

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 Ineffective airway clearance related to altered level of
consciousness.
 Risk of injury related to decreased level of consciousness
 Deficient fluid volume related to inability to take in fluids
by mouth
 Impaired oral mucous membranes related to mouth
breathing, absence of pharyngeal reflex, and altered fluid
intake
 Risk for impaired skin integrity related to immobility
 Impaired tissue integrity of cornea related to diminished
or absent corneal reflex
Nursing Diagnosis

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 Ineffective thermoregulation related to damage to
hypothalamic center
 Impaired urinary elimination (incontinence or retention)
related to impairment in neurologic sensing and control
 Bowel incontinence related to impairment in neurologic
sensing and control and also related to transitions in
nutritional delivery methods
 Disturbed sensory perception related to neurologic
impairment
 Interrupted family processes related to health crisis
Nursing Diagnosis

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Thank You!