Initial Approach to Managing a Patient with Altered Sensorium
The initial approach to a patient with altered sensorium must prioritize securing the airway, breathing, and circulation (ABC), followed by rapid assessment for life-threatening causes requiring immediate intervention. 1
Immediate Assessment and Stabilization
Primary Survey (First Minutes)
- Airway: Ensure patency; equipment to maintain a patent airway should be immediately available 2
- Breathing: Assess respiratory rate, effort, and oxygen saturation; provide supplemental oxygen if needed
- Circulation: Check vital signs, including blood pressure for signs of shock or hypertension 3
- Disability: Rapidly assess neurological status using Glasgow Coma Scale (GCS) 4
- Exposure: Quick examination for signs of trauma, rash, or other physical findings
Initial Vital Interventions
- Position patient to prevent aspiration (head elevation 30°)
- Establish IV access for medication administration and fluid resuscitation
- Apply cardiac monitoring
- Check blood glucose immediately (hypoglycemia is a rapidly reversible cause) 5
Focused Assessment
History (from family/witnesses if patient unable to provide)
- Onset and progression of altered mental status
- Recent medications, substance use, or toxin exposure 6
- Medical history (diabetes, epilepsy, psychiatric disorders, etc.)
- Recent trauma, fever, headache, or focal neurological symptoms
Physical Examination
Neurological assessment:
Look for specific signs:
- Fever (infection, encephalitis)
- Skin findings (rash, cyanosis, jaundice)
- Breath odor (alcohol, ketones)
- Signs of head trauma
Initial Diagnostic Workup
Immediate Laboratory Tests
- Complete blood count
- Basic metabolic panel (electrolytes, BUN, creatinine)
- Blood glucose
- Liver function tests
- Arterial blood gas (assess for acidosis) 5
- Blood cultures (if fever present)
- Toxicology screen when indicated 3
Imaging
- Brain imaging should be obtained when there are focal neurological deficits, suspected intracranial pathology, or no clear metabolic/toxic cause identified 7
- MRI is preferred when available, but CT is appropriate for initial rapid assessment 7
- Avoid routine head CT in patients with clear metabolic causes of altered mental status 7
Management Based on Suspected Etiology
Metabolic Causes
- Hypoglycemia: Administer IV glucose (50% dextrose)
- Diabetic ketoacidosis: IV fluids, insulin, and electrolyte replacement 5
- Electrolyte abnormalities: Correct sodium, calcium, or other imbalances 7
Infectious Causes
- Meningitis/Encephalitis: Start empiric antimicrobials immediately while awaiting diagnostic results 3
- Acyclovir 10 mg/kg IV every 8 hours (for suspected HSV encephalitis)
- Appropriate antibiotics based on suspected pathogens 3
Neurological Emergencies
- Seizures: Administer benzodiazepines (lorazepam 4 mg IV) for active seizures 3, 2
- Intracranial hemorrhage: Neurosurgical consultation for surgical candidates 8
- Increased intracranial pressure: Head elevation, osmotic agents if cerebral edema 3
Toxicologic Causes
- Specific antidotes when indicated (e.g., naloxone for opioids, methylene blue for methemoglobinemia) 6
- Enhanced elimination techniques when appropriate
Monitoring and Reassessment
- Frequent neurological assessments (every 15-30 minutes initially)
- Continuous cardiac and oxygen saturation monitoring
- Consider EEG monitoring if seizures are suspected 3
- Serial laboratory tests as indicated by clinical condition
Common Pitfalls to Avoid
- Assuming altered sensorium in elderly patients is due to dementia without thorough evaluation 7
- Failing to recognize non-convulsive status epilepticus
- Delaying antimicrobial therapy when infection is suspected 3
- Overlooking medication side effects or interactions as potential causes
- Neglecting to reassess patients after initial interventions
By following this systematic approach, clinicians can rapidly identify and address life-threatening causes of altered sensorium while establishing appropriate monitoring and treatment plans for ongoing management.