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GCS, Coma and Impaired Consciousness

In This Article

Pathophysiology

  • Consciousness is closely related to the reticular activating system.
  • This means that many focal brain lesions above the level of the RAS will not affect consciousness – unless the lesion causes downward pressure
 
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Intracranial causes of altered consciousness

Trauma
  • Head Injury
    • 2000 per 100 000 per year
    • 300 admitted to hospital per 100 000
    • 10 die per 100 000
    • The severity of the injury does not necessarily relate to the severity of the damage.
    • Battle’s sign – bruising over the mastoid process, a sign of fracture of the base of the skull.
    • Raccoon eyes – purple discolouration around the eyes due to fracture of the base of the skull.

Neoplasm

  • Most common brain tumour is GBM – glioblastoma. These are malignant. But benign tumours can also often be very dangerous due to location (compression, inoperable)
  • 50% of brain tumours are metastasis. 90% of these are in the posterior fossa.
  • Treatment of brain tumour
    • Surgery - Very hard to remove the whole thing – obvious you cant be generous with your excision boundary!
    • Radiotherapy
    • Chemotherapy

Infection

Seizures

Vascular

  • Haemorrhage (sub arachnoid, sub dural, extra dural)
  • Stroke
 
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Diagnosing altered consciousness

  • ABC’s
    • Hypotension cannot result from sub-arachnoid haemorrhage! If the patient has suffered trauma, and has low BP, it is likely to be caused by some other injury (e.g. dissection of aorta,  femoral artery)
  • GCS – Glasgow coma score (below)
  • History
  • Bloods, electrolytes, toxicity
  • Core neurological exam
  • Herniation syndrome of posterior fossa lesion
  • Give Medications
    • Glucose?
    • Naloxone – to reverse opioid overdose
    • Thiamine – in alcoholics
  • Exclude meningitis
    • Do an LP if there is no evidence of raised ICP and no coagulation problems!
  • Treat seizures
 
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Glasgow Coma Score - GCS

  • Out of 15
  • Minimum score is three
  • It is important to give a detailed GCS – give a breakdown, don’t just give the number!
  • 8 or less is technically a ‘coma’. You can’t intubate somebody with a GCS >8
 
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Eye Opening

  1. None
  2. To pain
  3. To speech
  4. Spontaneous
 
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Verbal response

  1. None
  2. Sounds
  3. Words
  4. Confused
  5. Orientated
 
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Motor Response

  1. None
  2. Extends to pain
  3. Flexes to pain
  4. Withdraws to pain
  5. Localises to pain
  6. Obeys commands 

- See more at: http://almostadoctor.co.uk/content/systems/neurology-psychiatry/neurology/coma-and-impaired-consciousness#sthash.zRgQfwSf.dpuf