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Vital sign level of consciousness



Management of Altered Level of Consciousness


<!--<h1>Management of Altered Level of Consciousness</h1>--> In contrast to the traditional approach in medicine, the comatose patient or the patient with a significant alteration in level of consciousness requires immediate management before completing the physical exam and acquiring the history. <br> The ABCs of resuscitation are followed. When an immobilized patient arrives in the emergency department, the cervical collar and backboard are left in place until a cause is found for the decrease in level of consciousness. <br> Naloxone (Narcan) 2 mg and thiamine (vitamin B-1) 100 mg are administered intravenously. If a fingerstick blood sugar is low or unavailable, glucose (50 cc of 50% dextrose) is administered after thiamine to reverse hypoglycemia. <br> Naloxone reverses the effects of a narcotic by competitive inhibition at the opioid receptor site. Thiamine prevents Wernicke s Encephalopathy, a rare neurological condition caused by thiamine deficiency seen in alcoholics with poor nutrition. Signs and symptoms include nystagmus, occular nerve palsy, ataxia and confusion. Thiamine functions as a coenzyme in the breakdown of glucose. Glucose given before thiamine depletes what little thiamine is available for glucose metabolism and may precipitate the syndrome. <br> Glucose and thiamine may be administered at the same time. Naloxone, thiamine and glucose were referred to in the past as a  coma cocktail and were often automatically administered. If a fingerstick glucose is normal, administering glucose is not indicated. The same applies to thiamine in the pediatric population. If a drug overdose is suspected, activated charcoal is administered by gastric tube after endotracheal intubation. <br><br> <strong>Increased Intracranial Pressure</strong><br><br> Increased intracranial pressure is a life-threatening event and must be dealt with immediately. Common causes are a head injury with intracranial bleeding and a hemorrhagic stroke. Signs include papilledema, loss of spontaneous venous pulsations, an increase in systolic pressure, bradycardia, an abnormal respiratory pattern and a fixed dilated pupil. <br> Carbon dioxide is a potent vasodilator in the brain and hyperventilation blows off carbon dioxide and reduces pressure. Mannitol is an osmotic diuretic that removes excess fluid from the brain. Increased intracranial pressure blocks blood flow to the brain, and the hypoxia triggers an increase in systolic pressure to re-establish flow. The increased blood pressure causes a baroreceptor decrease in heart rate, and pressure against the RAS of the pons and medulla decreases the heart and respiratory rates. The triad of increased blood pressure, decreased heart rate and irregular breathing is the Cushing reflex. In adults, often only the blood pressure rises. The triad occurs more often in pediatrics. Intracranial pressure may cause the brain to push against the third cranial nerve on that side causing a fixed dilated pupil, indicating compression of the lower part of the temporal lobe (uncus) against the tentorium cerebelli with impending herniation. <br> Treatment: intubation, hyperventilation, the head of the bed is raised 30 (except in the trauma patient with a cervical collar), furosemide 40 mg IV and/or mannitol 1 gm/kg IV is administered in consultation with a neurosurgeon.


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