Neurology Book

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Altered Level of ConsciousnessAka: Decreased Level of Consciousness

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  1. See also
    1. Dementia
    2. Delirium
    3. Psychosis
    4. Level of Consciousness
    5. Coma
    6. Approach to Coma
    7. Coma Exam
  2. Key Question: What is the cause of ALOC?
    1. See Altered Level of Consciousness Causes
    2. Toxic or metabolic condition
    3. Structural CNS disease
  3. Initial Management
    1. ABC Management
    2. Assess Level of Consciousness
    3. Protect patient and staff from injury
      1. Consider Physical or Chemical Restraints
      2. See Violent Behavior
    4. C-Spine immobilization (for suspected trauma)
    5. Abbreviated history and exam
    6. Intravenous Access
    7. Oxygen Delivery
    8. Vital signs including pulse oximetry
      1. Blood Pressure sensitive indicator of Brain Lesions
        1. Systolic Blood Pressure <90: Brain Lesion unlikely
        2. Systolic Blood Pressure >170: Brain Lesion likely
        3. Ikeda (2002) BMJ 325:800
  4. Initial Labs
    1. Glucose (Dextrostick or Glucometer)
    2. Complete Blood Count (CBC)
    3. Chemistry panel (chem7)
    4. Liver Function Tests
    5. Serum Osmolarity
    6. Serum Calcium
    7. Serum, Magnesium
    8. Urine Tox Screen
    9. Directed drug levels
      1. Digoxin level
      2. Theophylline level
      3. Phenobarbital level
    10. Urinalysis
    11. Arterial Blood Gas
    12. Rapid Plasmin Reagin (RPR)
    13. Thyroid Stimulating Hormone (TSH)
  5. Diagnostic studies to consider
    1. Electrocardiogram (EKG) and cardiac monitor
    2. Head CT
    3. Lumbar Puncture
    4. C-Spine films (if trauma suspected)
    5. Chest XRay
    6. Peritoneal tap
    7. Carboxyhemoglobin level
    8. HIV Test
    9. Heavy metal screen
    10. Vitamin B12 Level
    11. Serum Folate Level
  6. Management: Empiric Interventions
    1. Dextrose (bedside Glucometer first if possible)
      1. Adult: 50 ml of D50 IV
      2. Child: 4 ml/kg D25 (0.5-1.0 g/kg) IV
      3. Neonate: 5 ml/kg D10 (0.5 g/kg) IV
    2. Flumazenil
      1. Dosing
        1. Flumazenil 0.2 - 1.0 mg IV
      2. Precautions
        1. Tricyclic Antidepressant overdose
        2. Benzodiazepine Abuse
    3. Naloxone
      1. Adult: 2-4 mg IV
      2. Child: 0.1 mg/kg IV
    4. Thiamine
      1. Dosing
        1. Adult: 100 mg IV
        2. Child: 10-25 mg IV
      2. Indications
        1. Suspected Wernicke's Encephalopathy

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