From the Guidelines
If a patient has normal vitals but decreased responsiveness, the next step in management should be to perform a rapid neurological assessment while simultaneously calling for help. Begin with the AVPU scale (Alert, Voice, Pain, Unresponsive) to quantify their level of consciousness, followed by a focused neurological exam including pupillary response, motor function, and Glasgow Coma Scale assessment. Obtain point-of-care glucose testing immediately to rule out hypoglycemia, which is a rapidly reversible cause of altered mental status, as suggested by general medical knowledge and practices 1. If glucose is low (typically <70 mg/dL), administer 25g of dextrose IV (D50W) or 1mg of glucagon IM if IV access is unavailable. Consider naloxone 0.4-2mg IV/IM/intranasal if opioid overdose is suspected. Secure the airway if the patient cannot protect it, and position them in the recovery position if appropriate, as recommended by the 2022 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1. Simultaneously, gather a focused history from witnesses about the onset of symptoms, recent medications, and relevant medical history. This approach prioritizes identifying and treating immediately life-threatening conditions while preparing for more comprehensive evaluation including neuroimaging, laboratory studies, and possible lumbar puncture to determine the underlying cause, which could range from metabolic disorders to stroke, seizure, infection, or toxin exposure. Key considerations include:
- Ensuring accurate and complete vital sign measurement and documentation, as emphasized by the Society of Critical Care Medicine guidelines on recognizing and responding to clinical deterioration outside the ICU 1.
- Empowering patients, families, and care partners to recognize and report signs of clinical deterioration, as suggested by the same guidelines 1.
- Activating the emergency response system if the patient shows signs of severe hypothermia or decreased level of responsiveness, as indicated by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
From the Research
Next Steps in Management
If a patient's vitals are normal but they are showing decreased responsiveness, the next steps in management would involve a thorough diagnostic evaluation.
- The patient's history and neurologic examination are crucial in determining the cause of diminished responsiveness 2.
- A stepwise approach to the patient with an acute alteration in the content or level of consciousness should be taken, including a discussion of the spectrum of diminished responsiveness and a brief overview of the neuroanatomical localization of consciousness 2.
- The differential diagnosis of diminished responsiveness should be explored, followed by a discussion of the order and importance of laboratory, neuroimaging, and other ancillary tests 2.
- Sudden unresponsiveness with normal vital signs should trigger immediate and focused diagnostic evaluation to find or exclude those conditions requiring urgent, and possibly life-saving, management 3.
Diagnostic Evaluation
The diagnostic evaluation should include:
- A comprehensive assessment of the patient's medical history and current condition 3.
- Laboratory tests, such as lactate levels, and neuroimaging studies, such as CT or MRI scans, to help determine the cause of diminished responsiveness 2, 4.
- The use of anchor-based methods, such as patient-rated and clinician-rated variables, to evaluate the patient's responsiveness and determine the minimal important difference (MID) for patient-reported outcome (PRO) measures 5.
Predictive Factors for Clinical Deterioration
Several predictive factors for clinical deterioration have been identified, including: