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Assessment of Impaired Consciousness by Dr. Nin Bajaj, Neurologist, QMC & DRI

Dr. Nin Bajaj, a consultant neurologist, conducts detailed assessments using the Glasgow Coma Scale to diagnose different types of impaired consciousness, from acute to chronic conditions. Learn about the causes, symptoms, and management of various conditions affecting consciousness.

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Assessment of Impaired Consciousness by Dr. Nin Bajaj, Neurologist, QMC & DRI

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  1. Impaired Consciousness Dr Nin Bajaj Consultant Neurologist QMC & DRI

  2. Assessment • Glasgow Coma Scale • Eye opening-(E) • Spontaneous-4 • To speech-3 • To pain-2 • None-1

  3. GCS • Best Motor Response- (M) • Obeys-6 • Localises-5 • Withdraws-4 • Abnoraml flexion-3 • Abnormal extension-2 • None-1

  4. GCS • Verbal Response(V) • Orientated-5 • Confused conversation-4 • Inappropriate words-4 • Incomprehensible sounds-3 • None-1

  5. History • Acute • Subacute • Chronic

  6. Acute- quick recovery • Syncope- vasovagal, cough, micturition, carotid hypersensitivity, circulating volume • Apnoea- hyperventilation, sleep • Cardiac- arrythmia

  7. Acute impairment- no previous hx • Usually implies a vascular event • Hemispheric bleed or thrombo-embolic stroke • Subarachnoid haemorrhage • Brain-stem event • Bleed into a tumour?

  8. Acute impairment- previous hx • Might be post-ictal

  9. Subacute impairment • Hours-Days • Implies systemic or CSF process • Possibly raised ICP

  10. Subacute-systemic • Electrolyte imbalance- uraemia, hyperammonaemia, hypo/hypernatraemic • Endocrine- hypothyroid, Addisonian • Infection + with reduced cognitive reserve

  11. Subacute- CSF process • Meningitis/Encephalitis • Neoplastic • Inflammatory- ADEM, MS, Vasculitic, Sarcoid

  12. Subacute- raised ICP • Usually a rapidly growing tumour • Consider cerebral venous thrombosis • Might end up coning

  13. Chronic • Neurodegenerative- Lewy Body, Prion, AD • Chronic Vascular • Drug induced- e.g. Anti-cholinergics, dopaminergic agents • Sleep attacks e.g. narcolepsy, synuclein deposition

  14. Is it a stroke? • Hemispheric- should be localising neurology • Bleeds tend to be worse than embolic • Big MCA infarcts worse • Can be raised ICP complicating picture

  15. Is it a stroke? • Needs urgent CT brain • Outside UK, might thrombolyse • For big MCA, consider skull vault removal or dexamathasone/mannitol/over-breathing

  16. Thrombolysis for Stroke- Inclusion Criteria • Ischaemic stroke • Measurable deficit on NIH stroke scale • No evidence of intracranial bleed on CT brain • 180 minutes or less from time of symptom onset to intiation of IV rt-PA • IV rt-PA 0.9 mg/kg, 10% as bolus, 90% as infusion over 60 min

  17. Have they had a SAH? • Sudden onset • Worse headache ever, like “someone hitting me over the head” • Often nausea, vomiting, diplopia, neck stiffness, photophobia • Time to peak pain seconds-minutes • Pain can last hours, less often days

  18. Have they had a SAH? • Not to be confused with thunderclap headache or sex-associated headache • Sentinel bleed can occur • Need Urgent CT brain (remains abnormal for up to 6-10 days) • If negative, need LP after 12 hours and before 2 weeks (range 12-33 days) for xanthochromia

  19. Have they had a SAH? • If confirms dx, need nimodipine 60 mg/4hr PO, and fluids (>3l) • Consider urgent or elective clipping or neuroradiological coiling following formal angiography • Endovascular approaches generally best unless wide-necked aneursym

  20. Have they had a fit? • Classification • Generalised or partial • Grand mal or Petit mal (3Hz spike & wave) • Simple partial or Complex

  21. Have they had a fit? • Markers • Short, minutes only • Tongue biting, urinary incontinence, sterotyped movements • GTCS or CPS localising features • Drowsy and confused afterwards

  22. Causes • Usually primary- ?related to cellular migration defects or channelopathy • Secondary causes include SOL, drugs, stroke, alcohol

  23. Management • ABC • First fit- conservative, CT brain, refer to a neurologist • Known epileptic- review drug management

  24. Established Epilepsy- Drugs • Epilim for GTCS but not females • Lamotrigine GTCS in females • Tegretol for CPS or Lamotrigine if female • Phenytoin- status only

  25. Status Epilepticus • Definition: • “generalised convulsive status epilepticus in adults and older children (>5) refers to more than 5 minutes (USED to be 30 min) of (a) continuous seizures or (b) two or more discrete seizures between which there is incomplete recovery of consciousness”

  26. Status Epilepticus • Continuing seizure activity for >30 min • Diazepam 10-20 mg • Lorazepam 4 mg IV • ABC • Phenytoin, 15-18 mg/kg as IV over 20-30 min, cardiac monitor • Transfer to ITU, phenobarbitone and propofol, CFM

  27. Syncope and Seizure • Postural only? • Feel hot, clammy- “cold sweat” • Vision dark around edges • LOC seconds only • No tb, ui, drowsiness, confusion • ?arrythmia, pale as a sheet • micturition, cough, emotional trigger • Hyperventilation, migraine • Carotid sinus- e.g. stiff collar

  28. Investigating Syncope • ECG- look for WPW, long QT syndromes • If abnormal, 24hr ECG or loop monitor • Postural BP • Tilt table with CSM

  29. Management • Emotional or specific trigger- avoid stimulus • Neurogenic with positive tilt table- salt and fluids, orthostatic training, fludrocortisone, midodrine • Cardiac- pacemaker

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