ALTERED CONSCIOUS LEVEL82 General Medical Emergencies
(c) post-ictal state, complex partial (temporal lobe) seizures
(d) cerebrovascular accident, subarachnoid haemorrhage
(e) space-occupying lesion, e.g. tumour, abscess or haematoma
(f) hypertensive encephalopathy
(g) vasculitis such as systemic lupus erythematosus (SLE).
(iv) Metabolic
(a) respiratory, cardiac, renal or liver failure
(b) electrolyte disorder, such as hyponatraemia, hypercalcaemia
or hypernatraemia
(c) vitamin deficiency, e.g. thiamine (Wernicke’s
encephalopathy), nicotinic acid (pellagra) or B 12
(d) acute intermittent porphyria.
(v) Endocrine
(a) hypoglycaemia or hyperglycaemia
(b) thyrotoxicosis, myxoedema, Cushing’s syndrome,
hyperparathyroidism, Addison’s disease.
(vi) Septicaemia
(a) urinary tract, biliary, meningococcaemia or malaria.
(vii) Situational
(a) post-operative (multi-factorial including drugs, hypoxia,
infection, pain, etc.)
(b) faecal impaction, urinary retention or change in environment
in the elderly (rarely the sole cause).
4 Build up a picture of which condition or conditions are responsible from a
detailed history and examination.
5 Record the vital signs including temperature, respiratory rate, pulse, blood
pressure and Glasgow Coma Scale (GCS) score.
(i) Any abnormality of the vital signs should be assumed to have an
organic cause until proven otherwise.
6 Document a formal Mini-Mental State Examination (see Table 2.7).
(i) This records cognitive impairment by assessing orientation,
attention and calculation, immediate and short- term recall,
language, and ability to follow simple verbal and written
commands.
(ii) A score of ≤20 suggests cognitive impairment, and the possibility
of an organic cause.
7 Perform some or all of the following investigations based on the suspected
aetiology. Always exclude hypoglycaemia:
(i) FBC, coagulation profile.
(ii) U&Es, blood sugar, liver function tests, calcium, thyroid function
tests.
(iii) Drug screen including ethanol.
(iv) ABGs.