Altered Consciousness

Altered Consciousness – Treatment Overview

Introduction
Altered consciousness refers to any disturbance in a patient’s level of awareness, ranging from mild confusion or disorientation to deep coma. It is a clinical presentation, not a disease, and can be caused by diverse conditions including trauma, stroke, seizures, infections (e.g., meningitis, encephalitis), metabolic disturbances (e.g., hypoglycemia, electrolyte imbalance), intoxication, or hypoxia. Management requires rapid assessment, stabilization of vital functions, and treatment of the underlying cause to prevent irreversible brain damage.

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Emergency Management (Immediate Priorities)

1. Stabilization (ABCDE Approach)

• Airway: Ensure airway patency, consider intubation if GCS ≤ 8.

• Breathing: Administer oxygen to maintain saturation >94%.

• Circulation: Monitor blood pressure and pulse; establish IV access.

• Disability: Rapid neurological exam (Glasgow Coma Scale, pupillary responses).

• Exposure: Look for trauma, rashes, drug paraphernalia, medical alert tags.

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Empirical/Initial Therapy (while searching for cause)

• Hypoglycemia: Dextrose 25–50 mL of 50% IV bolus, then infusion if needed.

• Suspected Wernicke’s encephalopathy (alcoholism/malnutrition): Thiamine 100 mg IV before glucose.

• Opioid overdose: Naloxone 0.4–2 mg IV every 2–3 minutes as needed (max 10 mg).

• Seizure activity: Lorazepam 4 mg IV (may repeat once after 10–15 min).

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Targeted Therapy (Based on Underlying Cause)

1. Stroke / Intracranial Hemorrhage

• Neuroimaging (CT/MRI) urgently.

• Thrombolysis or thrombectomy in ischemic stroke if within treatment window.

• Blood pressure and intracranial pressure control in hemorrhagic stroke.

2. Traumatic Brain Injury

• Elevate head, prevent hypoxia and hypotension.

• Neurosurgical intervention if needed (hematoma evacuation).

3. Infections (e.g., meningitis, encephalitis, sepsis)

• Empiric antibiotics (e.g., ceftriaxone 2 g IV every 12 hours) ± antivirals until cause confirmed.

4. Metabolic / Toxic Causes

• Correct electrolyte imbalances (e.g., sodium, potassium, calcium).

• Dialysis for severe intoxications (e.g., lithium, ethylene glycol).

5. Hypoxia / Cardiac Arrest

• Immediate oxygenation, airway management, and advanced cardiac life support (ACLS) if required.

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Supportive and Monitoring Measures

• Admit to ICU if unstable or comatose.

• Continuous monitoring: ECG, oxygen saturation, blood pressure.

• Regular neurological reassessment (GCS, pupils, limb movements).

• Prevent complications: aspiration pneumonia, pressure sores, deep vein thrombosis.