What is the approach to a patient with altered level of consciousness (ALOC)?

From the Guidelines

The approach to altered level of consciousness (ALOC) should begin with the ABCDE assessment (Airway, Breathing, Circulation, Disability, Exposure) to stabilize the patient, as recommended by multiple studies including 1, which emphasizes the importance of rapid identification and treatment of critically injured patients. The first step in managing ALOC is to secure the airway and provide supplemental oxygen if needed, then establish IV access for fluid resuscitation and medication administration.

• Quickly check vital signs and glucose levels using a point-of-care glucometer.
• For hypoglycemia, administer 50mL of 50% dextrose IV (D50W) or 1mg of glucagon IM if IV access is unavailable.
• For suspected opioid overdose, give naloxone 0.4-2mg IV/IM/intranasal and repeat as needed.
• If alcohol withdrawal is suspected, administer benzodiazepines such as lorazepam 2-4mg IV or diazepam 5-10mg IV. Perform a focused neurological examination using the Glasgow Coma Scale to quantify the level of consciousness, as suggested by 1, which recommends transport to a facility that provides the highest level of care within the defined trauma system if the Glasgow Coma Scale is ≤13. Obtain relevant history from family or bystanders about the patient's medical conditions, medications, and events preceding the ALOC. Order laboratory tests including complete blood count, comprehensive metabolic panel, toxicology screen, blood gases, and ammonia levels. Imaging studies such as head CT should be performed to rule out structural causes, as recommended by 1 and 1, which emphasize the importance of access to neuroimaging and neurophysiology in the management of suspected acute encephalitis. The ALOC approach is systematic because the brain's function can be affected by numerous conditions including metabolic disorders, infections, trauma, toxins, and primary neurological events, requiring rapid identification and treatment of the underlying cause to prevent permanent neurological damage, as highlighted by 1 and 1.

From the FDA Drug Label

The toxic dose of barbiturates varies considerably. In general, an oral dose of 1 gram of most barbiturates produces serious poisoning in an adult. Acute overdosage with barbiturates is manifested by CNS and respiratory depression which may progress to Cheyne-Stokes respiration, areflexia, constriction of the pupils to a slight degree (though in severe poisoning they may show paralytic dilation), oliguria, tachycardia, hypotension, lowered body temperature, and coma Typical shock syndrome (apnea, circulatory collapse, respiratory arrest, and death) may occur. In extreme overdose, all electrical activity in the brain may cease, in which case a "flat" EEG normally equated with clinical death cannot be accepted. Consideration should be given to the possibility of barbiturate intoxication even in situations that appear to involve trauma. Complications such as pneumonia, pulmonary edema, cardiac arrhythmias, congestive heart failure, and renal failure may occur. Uremia may increase CNS sensitivity to barbiturates Differential diagnosis should include hypoglycemia, head trauma, cerebrovascular accidents, convulsive states, and diabetic coma.

The approach to altered level of consciousness involves considering the possibility of barbiturate intoxication, even in situations that appear to involve trauma. Key considerations include:

• CNS and respiratory depression
• Cardiovascular complications such as hypotension, cardiac arrhythmias, and congestive heart failure
• Renal complications such as oliguria and renal failure
• Differential diagnosis including hypoglycemia, head trauma, cerebrovascular accidents, convulsive states, and diabetic coma Treatment is mainly supportive and consists of:
• Maintenance of an adequate airway, with assisted respiration and oxygen administration as necessary
• Monitoring of vital signs and fluid balance
• Fluid therapy and other standard treatment for shock, if needed
• Consideration of forced diuresis or hemodialysis in severe cases 2

From the Research

Altered Level of Consciousness Approach

• The initial priorities in managing altered level of consciousness are to ensure a clear airway, and that breathing and circulation are adequate, as problems with airway, breathing or circulation can lead to an altered level of consciousness 3.
• A child who presents to the emergency department with an altered level of consciousness can be clinically unstable and can pose a great diagnostic challenge, requiring the emergency clinician to quickly develop a wide differential of possible etiologies in order to administer potentially life-saving medications or interventions 4.
• The assessment of adult patients with traumatic brain injury with Glasgow Coma Scale 13-15 at the emergency department should focus on a practical recommendation for the assessment of these patients, including the use of acute head computerized tomography (CT), biomarkers, and disposition after ED care 5.
• In clinical practice, hospital admission of patients with altered level of consciousness requires an effective investigation and early treatment, with a focused and objective evaluation, quality history taking, and physical examination capable of locating the lesion and defining conducts 6.
• Mannitol therapy for raised intracranial pressure (ICP) may have a beneficial effect on mortality when compared to pentobarbital treatment, but may have a detrimental effect on mortality when compared to hypertonic saline, and ICP-directed treatment shows a small beneficial effect compared to treatment directed by neurological signs and physiological indicators 7.

Key Considerations

• Ensuring a clear airway, breathing, and circulation is crucial in managing altered level of consciousness 3.
• Developing a wide differential of possible etiologies is essential in diagnosing and treating altered level of consciousness in emergency departments 4.
• A multidisciplinary approach is necessary for the assessment and management of traumatic brain injury patients with altered level of consciousness 5.
• A focused and objective evaluation, including quality history taking and physical examination, is critical in locating the lesion and defining conducts in patients with altered level of consciousness 6.
• The effectiveness of mannitol therapy for raised ICP depends on the comparison treatment, and ICP-directed treatment may have a small beneficial effect on mortality 7.