Level of Consciousness
November 26th, 2019
Overview
Patients with hepatic encephalopathy in the setting of acute or chronic liver disease may be confused or have a reduced level of consciousness.
The Glasgow Coma Scale (GCS)
15-point scale indicating level of consciousness.
How to Assess
- If the patient is not spontaneously opening their eyes, begin by attempting to elicit a response verbally. If this is unsuccessful then apply a painful stimulus such as a trapezius squeeze or a sternal rub.
If not done in this order, the examiner is unable to determine whether the patient responded to the painful stimulus or the voice.
Interpretation
![The Glasgow Coma Scale (GCS)]()
Causes of Unconsciousness
Intracranial
- Haemorrhage - intracerebral, subarachnoid, subdural, extradural
- Infarction
- Infection - meningitis, encephalitis, abscess
- Tumour - mass effect, cerebral oedema
- Post ictal state
- Head trauma - vascular, hypoxia, cerebral oedema, parenchymal injury
- Psychiatric - conversion, depression, catatonia
Extracranial
- Cardiovascular - shock, hypertension
- Infection - septicaemia
- Metabolic - hypo/hyperosmolar states, hypo/hyperglycaemia, hypoadrenalism, hypothyroidism, hypopituitarism, electrolyte abnormality, hypoxia, hepatic failure, renal failure
- Drugs / toxins - sedatives, analgesics, alcohol, encephalopathy
- Physical injury - hyper / hypothermia, electrocution
Assessing Orientation
Ask About
- Time - day, date, month, year, season
- Place - floor, building, city, state, country
- Person - full name, date of birth, address
Significance
- Orientation is a quick way of assessing patients for confusion.
Causes of Confusion
- Delirium - stroke, infection, intoxication / withdrawal, metabolic, neoplastic, seizure, sleep deprivation, severe pain, psychiatric
- Dementia - Alzheimer's, vascular dementia, lewy body dementia
- Intellectual disability
- Poor compliance with examination
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