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

responds to Voice

responds to Pain

Unresponsive

Glasgow Coma Scale

Assesses
Value
3

patients neurological condition

range 3 to 15

totally comatose patient

15

fully alert patient

Classification of Brain Injury

According to Glasgow Coma Scale
(GCS)
(HICKEY 2003)
SEVERE
GCS 3-8
MODERATE
GCS 9-12
MILD
GCS 13-15

Neurological chart
GCS

top section

Temperature/BP/pulse/respiratory
Pupil

size / reaction to light

Limb

movement arms and legs

rate

Eye opening
Spontaneous
To speech
To pain
None

=3

=2

=1

=4

Verbal response
Orientated

=5

Disorientated

=4

Monosyllabic

=3

Incomprehensive
None

=1

=2

Motor response
Obeys

commands = 6

Localises

pain = 5

Withdrawal
Flexion

to pain = 3

Extension
None

to pain = 4

=1

to pain = 2

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) 5th 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
Skin

risk of aspiration

damage

Corneal

ulceration