Alteration of Consciousness

Management of Alteration of Consciousness (AOC)

Initial Management

• Consciousness Assessment: Determine if the patient is responsive. If responsive, proceed with ABC (Airway, Breathing, Circulation). If unresponsive, proceed with CAB (Circulation, Airway, Breathing) ± BLS (Basic Life Support) and check CBG (Capillary Blood Glucose) or DTX (Dextrose).

• Trauma vs. Non-Trauma:

• Trauma Cases: Important to consider C-spine injury. Consider ETT (Endotracheal Tube) if GCS ≤ 8 and look for signs of brain herniation (Cushing’s response, altered respiratory rate, abnormal pupillary light reflex, impaired brainstem reflex).

• Non-Trauma Cases: Look for reversible causes such as intoxication/toxin exposure and metabolic causes like hypoglycemia. ETT may be necessary for airway protection.

Orders for Initial Management

• Oxygen: If there's hypoxia or hypoventilation.

• IV Fluid: For hypotension.

• Hypoglycemia Management: Administer 50% glucose IV push for levels <55 mg% (non-DM) or <70 mg% (DM). If risk of chronic alcohol consumption or malnutrition, add Thiamine.

• Opioid Overdose: Naloxone 0.4-2 mg IV, titrate to avoid withdrawal.

• Benzodiazepine Overdose: Flumazenil IV 0.2 mg/min (max 1 mg), use with caution.

• Intoxication Management: Consider gastric lavage and activated charcoal.

Post-Stabilization Management

• History Taking: Focus on onset, progression, and circumstances before AOC, including fever, seizures, and medication use.

• Neurological Assessment (CPOMR): Consciousness level, GCS score, pupillary reflex, ocular examination, motor and meningeal signs, and respiratory pattern.

Specific Management Based on Cause

1. Structural Brain Defects (Trauma, Vascular Issues, Infection, etc.): Non-contrast CT brain Emer recommended.

2. Possible Infection: Manage with empirical antibiotics, consider lumbar puncture or NCCT brain before LP in certain cases.

3. No Focal Neurological Deficit and Absent Meningeal Signs (Drugs, Metabolic, Vascular, Systemic, Nutritional, Seizure, etc.): Conduct toxic/metabolic workup based on suspected cause.

Medications and Orders

• Glucose: For hypoglycemia, 50% glucose 50 mL IV push.

• Thiamine: Before glucose in cases of chronic alcohol consumption, 100 mg IV stat.

• Ceftriaxone (Cef-3): For empirical meningitis treatment, 2 g IV every 12 hours.

• Dilantin: For seizure prophylaxis in ICH or empirical NCSE, 1000 mg IV drip.

• Mannitol: For cytotoxic edema, 20% mannitol 250 mL IV drip.

• Nicardipine: For BP control in stroke/ICH.

• Dexamethasone: For vasogenic edema, 10 mg IV stat then 4 mg IV every 6 hours.

• Lactulose: For hepatic encephalopathy, 30 mL PO tid.

This summary addresses the critical steps in managing patients with altered levels of consciousness, emphasizing initial stabilization, comprehensive assessment, and targeted treatment based on underlying causes. Others Orders those may useful. Alteration of Consciousness

Disease - Investigation/Risk factor - Initial management

• Wernicke Encephalopathy

• Classic triad: Encephalopathy, Oculomotor dysfunction, Gait ataxia

• Initial Management: 500 mg thiamine IV infused over 30 minutes three times a day for two days then 250 mg IV or IM once daily for 5 days.

• Risk Factor: Chronic alcohol drinking.

• Hepatic Encephalopathy

• Liver Insufficiency (High Child-Pugh score)

• Correcting precipitate causes: BIG SCALP. Lower blood ammonia: 1st line Lactulose 30 - 45 mL (20 to 30 g) orally three to four times a day depending on the severity and liver function. If not improved in 48 hours, add rifaximin 400 mg orally three times a day or 550 mg orally twice a day.

• Vasogenic Brain Edema

• Investigation: CT brain non-contrast

• Initial Management: Dexamethasone 10 mg IV stat then 4 mg IV every 6 hours.

• Brain Abscess

• Investigation: Hemo culture, CSF culture, CT non-contrast

• Empiric Antibiotics by source:

• Oral, otogenic, sinus: Metronidazole 500 mg IV every 6-8 hours plus Ceftriaxone 2 mg IV every 12 hours.

• Hematogenous: Vancomycin 15 - 20 mg/kg IV every 8 - 12 hours.

• Post penetrating trauma: Vancomycin 15 - 20 mg/kg IV every 8 - 12 hours + Ceftriaxone 2 mg IV every 12 hours.

• BP Control in Stroke and ICH

• Investigation: BP measuring

• Initial Management:

• 1st option: Nicardipine (short half-life) 5 mg/hour IV, titrate up to desired effect by 2.5 mg/hour every 5 to 15 minutes, maximum 15 mg/hour OR

• 1st option: labetalol 10 mg IV followed by continuous infusion 2 to 8 mg/min.

• Target:

• Ischemic stroke: Maintain BP at or below 180/105 mmHg after rTPA. Maintain BP more than 185/110 mmHg if eligible for rTPA.

• Hemorrhagic stroke / ICH: SBP < 140 mmHg (in cases with initial SBP between 150 - 220 mmHg), SBP < 140 -160 mmHg (in cases with initial SBP > 220 mmHg).