What is the treatment algorithm for a patient presenting with decreased sensorium?

Treatment Algorithm for Decreased Sensorium

The treatment of decreased sensorium should follow a systematic approach that prioritizes identifying and addressing the underlying cause while ensuring adequate cardiorespiratory monitoring and neurological assessment.

Initial Assessment and Stabilization

1. Airway, Breathing, Circulation (ABC) Assessment

   • Ensure patent airway and adequate oxygenation
   • Monitor vital signs continuously
   • Establish IV access for medication administration

2. Rapid Neurological Evaluation

   • Glasgow Coma Scale assessment
   • Pupillary reflexes and size
   • Motor responses and focal neurologic deficits
   • Check for signs of increased intracranial pressure

Diagnostic Workup

Immediate Investigations

• Bedside glucose measurement - to rule out hypoglycemia
• Arterial blood gas - to assess oxygenation, ventilation, and acid-base status
• Serum electrolytes - particularly sodium and potassium levels
  • Severe hypokalemia can mimic brain death 1
  • Hyponatremia correlates with depression of sensorium and seizures 2

Laboratory Tests (Based on Clinical Suspicion)

• Complete blood count
• Renal and liver function tests
• Toxicology screen (including cannabis in infants with unexplained encephalopathy) 3
• Blood cultures if infection suspected

Imaging Studies

• MRI brain with dedicated protocol is preferred over CT for most neurological causes 4, 5
• CT head without contrast should not be routinely ordered unless specific indications exist 5
• For patients with focal neurologic findings, MRI with internal auditory canal protocol is recommended 5

Common Etiologies and Specific Management

Metabolic Causes

1. Electrolyte Abnormalities

   • Hyponatremia: Correct sodium levels cautiously (avoid rapid correction)
   • Hypernatremia: Gradual correction with hypotonic fluids
   • Hypokalemia: Potassium replacement therapy 1
   • Hypercalcemia or Hypocalcemia: Calcium correction

2. Diabetic Emergencies

   • Diabetic ketoacidosis: Insulin infusion, fluid resuscitation, electrolyte replacement 4
   • Hypoglycemia: IV glucose administration

Neurological Causes

1. Seizures

   • Anticonvulsant therapy
   • Continuous EEG monitoring in refractory cases
   • Cardiorespiratory monitoring for patients with seizures 4

2. Intracranial Pathology

   • Stroke: Thrombolytic therapy if ischemic and within time window
   • Hemorrhage: Blood pressure control, reversal of anticoagulation if applicable
   • Infection: Appropriate antimicrobial therapy

Toxic/Infectious Causes

1. Intoxication

   • Supportive care
   • Specific antidotes if available
   • Consider hemodialysis for certain toxins

2. Infections

   • Meningitis/Encephalitis: Empiric antimicrobials pending cultures
   • COVID-19: Supportive care, as altered sensorium may result from hypoxia and metabolic abnormalities 6

Level of Care Determination

• Intermediate Care Admission Criteria 4:

  • Altered sensorium in whom neurologic deterioration is unlikely
  • Neurologic assessment not required more often than every 2 hours
  • Stable cardiorespiratory status requiring monitoring

• ICU Admission Criteria:

  • Rapidly deteriorating neurological status
  • Requirement for mechanical ventilation
  • Hemodynamic instability
  • Need for frequent neurological assessments (more than every 2 hours)

Follow-up and Monitoring

1. Continuous Monitoring

   • Vital signs
   • Neurological status using standardized scales
   • Oxygenation and ventilation parameters

2. Serial Assessments

   • Repeat laboratory tests based on initial abnormalities
   • Follow-up imaging as indicated by clinical course

3. Rehabilitation Planning

   • Early involvement of rehabilitation services for patients with persistent neurological deficits

Special Considerations

• In pediatric patients with unexplained encephalopathy, consider toxin ingestion including cannabis 3
• In patients with COVID-19, be vigilant for neurological manifestations as part of the disease process 6

Remember that decreased sensorium represents a symptom rather than a diagnosis, and identifying and treating the underlying cause is paramount to improving patient outcomes.