Definition :- Consciousness

Consciousness is defined as a general awareness of oneself and the surrounding

environment. (Hickey 1997) - capable of responding to sensory stimuli.
It is a dynamic state and can therefore, change. Eg. Waking from sleep.
In the same way Unconsciousness incapable of responding to sensory stimuli .
Consciousness is described as having two parts to it:
Arousal or wakefulness - a function of the reticular activating system (RAS) located in the
brainstem.
Awareness or cognition - a function of the cerebral hemispheres.

Underlying Mechanism
Consciousness is dependent upon the cerebral hemispheres being intact and interacting
with the ascending RAS.
It is maintained by a constant stream of impulses that are sent from the brain stem
upwards into the two cerebral hemispheres.
Loss of consciousness therefore has two general mechanisms.

Cerebral Hemisphere Malfunction


Altered Consciousness.


Brain Stem Malfunction
Cerebral Hemisphere Malfunction.
Drug and alcohol intoxication.
Hypoxic brain injury.
Stroke.
Metabolic disorders.
Infection.
Post seizure.
Brain Stem Damage.
Direct Damage.
Brain Stem Infarct.
Indirect Damage (pressure from above).
Cerebral Mass (clot, tumour, abscess)
Cerebral Oedema (infarct, hypoxia, infection, injury)

Alterations in conscious level may be slow and progressive or may be acute.
Loss of consciousness may be brief or may be prolonged.
Accurate assessment of conscious level is one of the most important roles of the
health care practitioner.
Altered Consciousness :-
Pathological Causes of Decreased Conscious Level :-
Brain Injury /
Irritation.
Increase in Brain
Volume.
Increase in
Cerebral Blood
Volume.
Increase in CSF
Volume.
Metabolic
Causes.
Drugs and
Poisoning.

Brain Injury / Irritation.
Cerebral infection - encephalitis / meningitis.
Brain infarction, Post seizure.
Increase in Brain Volume:-
Brain tumours, Cerebral oedema from head injury,Cerebral abscess.
Increase in Cerebral Blood Volume:-
Extradural haematoma, Subdural haematoma, Subarachnoid
haemorrhage ,Intracerebral haematoma.
Increase in CSF Volume:-Hydrocephalus
>Generalised metabolic or toxic disorders can depress brain function
Metabolic Causes:- Major organ failure. (E.g liver or kidney
failure) * Metabolic acidosis. *Hypoxia. *Hypo /
Hyperglycaemia. (blood sugar < 3 mmol/L = coma and possible
fitting) *Electrolyte imbalance. (E.g disturbances of calcium,
sodium and potassium.) *Pituitary, adrenal and thyroid disease.
(E.g Hypothyroidism) *Cardiac Arrhythmias (E.g fast atrial
fibrillation) , * Hypothermia.
Drugs / Poisoning:- Sedatives - barbiturates, opiates.
Amphetamines - tricyclic antidepressants.
Steroids , Salicylates , Anticonvulsants, Alcohol, Poisons.
Precipitating Factors :-
Age: The incidence of altered consciousness increases with age.
Cardiovascular status: Disorders that lower cardiac output, lower
perfusion and precipitate arrhythmias.
Pulmonary disorders: Disorders that cause hypoxia and hypoxaemia.
Drug therapy: Sedation, analgesia, drug toxicity, drug interactions.
Cerebral disorders: Including expanding lesions and brain injury.
Surgical factors: Prolonged anesthesia time.
Perceptual / sensory factors: Sleep deprivation, sensory overload,
sensory deprivation.
Metabolic factors: Changes in glucose level, hypermetabolism,
hypometabolism.
Fluid and electrolyte disturbances: Sodium and potassium
imbalances, hypovolaemia.
Assessment and Management
Priorities:-
Establish exactly what happened.
Immediate assessment (life threatening conditions).
General assessment.
Investigations.
Management plan
Continue to monitor.
Investigations: Blood and Urine, Drug screen, U and E,
glucose, calcium, LFTs, ABGs, thyroid, cortisol levels, blood
cultures etc. CT / MRI Scanning. CSF investigations.
Assessment :-
Vital signs > Level of consciousness.
Motor function. > Pupillary signs.

Vital Signs:-
Changes in respiration, in terms of rate and pattern of
breathing, can give a good idea of the function of the brain
stem.
Alterations in temperature may be due to damage to the
hypothalamus.
Rising blood pressure and falling heart rate may = increasing
ICP. (Cushings sign)
Glasgow Coma Score:-
The most widely used scoring system for quantifying
consciousness.
Allows standardisation of assessment.
Consists of three aspects of behavioural response, each
evaluated independently.
Eye opening.
Best verbal response.
Best motor response.
It assesses the two aspects of consciousness: arousal and
cognition.
Highest score = 15
Lowest score = 3 (even patients who are brain stem dead
score 3)
The phrase GCS of 10, 12 etc is largely meaningless and the
figure should be broken down as E3V3M4, E3V4M4 etc.
A patient scoring of eight or less is considered to be in a deep
coma.
Painful Stimuli?
When performing the GCS, you are trying to illicit a
purposeful and specific response to painful stimuli (not just a
response to the irritation).
As such stimuli that causes the patient to respond
purposefully are favoured (across the midline and up) .
Trapezius pinch? Supraorbital ridge? (Not in facial #)
Jaw margin? (Not in facial #) Lateral aspect of fingers?
Sternal rub?
Inflicting a painful stimulus may not always be needed, as the
patient may find objects such as nasogastric tubes and oxygen
masks irritating, and may localise spontaneously to such
sources of irritation.
Posturing:-
Decorticate:
The upper extremities are flexed at the elbows and wrists. The legs
may also be flexed. Consider lesion in a mesencephalic (mid-brain)
region of the brain.
Decerebrate:
The arms are extended and internally rotated. The legs are extended
with the feet in forced plantar flexion.
Consider compression of the brain stem at a low level.
Assessing for Pupillary Changes:-
Assessment of the pupils looks at the function of two cranial nerves.
Cranial nerve III (oculomotor) constricts the pupil?
Cranial nerve II (optic) reacts to light being shone into the eye?
Pupillary Changes: -
Not a true component of GCS.
Pupils are assessed for their reaction to light, size and shape.
A change in pupil response to light and size indicates raised
ICP and / or compression of the cranial nerve that controls
pupil constriction.
Look at the resting size of both pupils - the average size is 2 to
5 mm.
Look at the shape of the pupil - normally pupils are round.
Abnormal shapes are oval or irregular.
Look to see if both pupils are equal in size.
Look to see if both pupils react to light - consensual reaction.
--Brisk reaction / some or sluggish reaction / no reaction.
* Tricyclic antidepressant OD = bilateral fixed and dilated pupils.
* Opiate and benzodiazepine OD = bilateral fixed and constricted
pupils.
* Unilateral dilation of a pupil with loss of light reflex may =
uncal herniation. (herniation of temporal lobe)
Management of the Unconscious Patient:-
ABC. > SAFETY






















Inadequate airway /
poor gag reflex.
Positioning.
Artificial airways.
(NB Cervical spine)
Ineffective clearance of
secretions / poor cough
reflex.

Assessment.
Use of suction.
Physiotherapy.
Positioning.

Poor respiratory
pattern / altered gas
exchange.

Physiotherapy.
Positioning.
Oxygen therapy.
Monitoring.