3-9. DISORDERS OF CONSCIOUSNESS

a. Definition of Disorders of Consciousness. These disorders, either intracranial or extracranial, have a common cause which is loss of consciousness.

b. Causes of Disorders of Consciousness. An intracranial (inside the skull) disorder of consciousness can be caused by a tumor (compression of the upper brainstem, a stroke, seizure, intracranial pressure (ICP), or by metabolic changes such as hypoglycemia or toxic ketoacidosis. An extracranial disorder may be caused by trauma, electrical shock, drugs, and gases.

c. Signs/Symptoms of Disorders of Consciousness. These signs and symptoms could be a change in the patient's level of consciousness. In this case, the patient is alert and oriented. However, the patient could be lethargic, that is, sleepy or drowsy but able to be awakened and respond appropriately to a command. The patient could be in a stupor or spontaneous unconsciousness when it would be difficult to awaken him. The patient could be in a semicoma in which pain would arouse him. A patient in a coma cannot be aroused, even with painful stimuli. Changes in the level of consciousness are a primary diagnostic symptom which can be assessed and monitored. An initial baseline evaluation of the patient's level of consciousness is a necessity. Other signs and symptoms of disorders of consciousness include the following:

(1) Trauma to the head. Automobile accidents, motorcycle accidents, and falls from ladders, rooftops, etc., can cause such trauma.

(2) Abnormalities in the rate, depth, and odor of respirations.

(3) Changes in the pupils of the eye, responsiveness to light, diameter of the pupil, and speech reaction.

(4) Changes in the corneal reflex.

(5) Seizures. In this case, check respirations and prevent aspiration.

(6) Fluctuation of rectal temperatures due to hypothalamus malfunctions.

d. Treatment of Disorders of Consciousness. The main goal in treatment is to maintain life until diagnosis can be determined. Treatment consists of maintaining the patient's airway, breathing, and circulation (the ABCs). Spinal injury is always suspected in cases of disorders of consciousness. Immobilize the patient accordingly so that he does not further injure himself. Maintain an IV until the patient's intracranial status can be determined. Treatment of consciousness disorders should include a baseline physical examination to include checking the baseline level of consciousness (LOC) of the patient. Check his level of consciousness by asking him if he lost consciousness at any time, how long he has been oriented since then, and if he feels he is experiencing any personality changes. Another part of the rapid baseline physical examination is an evaluation of vital signs. This evaluation should include:

(1) Rechecking vital signs every 15 minutes.

(2) Checking temperature fluctuations. Fluctuations in temperature may indicate a malfunction of the hypothalamus.

(3) Checking the pulse. Bradycardia would indicate increased cranial pressure (ICP).

(4) Checking respirations. Check for Cheyne-Stokes, central neurogenic pattern, and hypoventilation. Initially, an increase in the depth of respirations with no significant change in rate of respirations may be seen. Later the rate of respirations may increase, but eventually respiratory depression occurs.

(5) Checking blood pressure. An increase in blood pressure may indicate increased, intracranial pressure. Try to assess for evidence of trauma and intoxication. Do this by inspecting the head and neck for injury. If trauma is suspected, use a clinical collar.

(6) Establish baseline vital signs, pupil size, corneal reflex, and check for the presence of movements, reflexes, and paralysis of the extremities.