Diving Right In

 It seems I jumped straight into the deep end with my recent posts and forgot to cover the basics of assessing consciousness. That is our subject for today. 

Consciousness is regulated by the brain’s cerebral hemispheres and what’s called the ‘Reticular Activating System.’ The cerebral hemispheres are responsible for awareness and understanding, while the RAS, located in the upper brainstem, regulates arousal (let’s be mature, here). When a threat arises in your environment, the RAS alerts the cerebral hemispheres, which then launch a physical, emotional, or intellectual response to the threatening stimulus. Think of the RAS as a bridge connecting mind and body. It filters and prioritizes sensory information so that your cerebral mind can focus on the relevant features of your environment. 

When first approaching a victim, your immediate tasks are to identify threats to life and establish strategies to mitigate them. The most pressing consideration is whether the patient’s condition is emergent or non-emergent –  “emergent” simply meaning “in need of immediate medical attention.” 

Emergent conditions include: 

• Poor general impression or decreased level of consciousness

• Unresponsive

• Signs and symptoms of shock (I will cover this in-depth on another day)

• Severe pain

• Multiple injuries

• Difficulty breathing

• Chest pain together with alarming skin symptoms, such as paleness, coolness, or excessive sweating.

• Uncontrolled bleeding

To assess the emergency, we begin by assessing the level of consciousness (LOC) and identifying any airway, breathing, or circulation (ABC) problems. (If you need a refresher, I covered basic airway assessments in this post).

When evaluating LOC, we are essentially evaluating the RAS’s connection to the cerebral hemispheres. Assessments are fluid – we continuously update our understanding of the situation, upgrading or downgrading the patient based on what we know. 

Usually, your first assessment will be to determine responsiveness. The acronym to remember is AVPU – Alert, Verbal, Pain, Unresponsive. Is the patient Alert? Do they respond to Verbal stimuli? Do they respond to pain? Or are they totally Unresponsive? 

A patient is alert if they respond spontaneously to what’s happening around them. If the patient is alert, we must determine mentation (mentation is the process of reasoning and thinking) using follow up questions: 

• “What is your name?” (Alert to person) 

• “Where are we?” (Alert to place) - Any correct answer is acceptable. 

• “What year and month is it?” (Alert to time) - It’s always relieving when a drunk can rattle off the full date and time right after getting their face punched in. But I digress. 

• “What happened” (Alert to event) 

If the patient is alert but answers any of these questions incorrectly, their consciousness is “altered.” 

If they are not alert, test to see whether they react to verbal stimuli like a tap on the foot and a “hey, are you okay?” If you can elicit a moan or grimace by shouting, the patient is responsive. 

If they are not alert nor responsive to verbal stimuli, test their pain reaction with a light pinch of the trapezius muscle. 

If the patient does not respond to any of the above, they are considered unresponsive. 

Let's use a real world scenario:

You’re scouring the shelves at the local grocery store, mumbling under your breath about the price of Fruit Loops, when a 70 year old woman collapses at the other end of the cereal aisle. 

As you approach, you are already making your “across the room” assessment, evaluating skin signs, breathing, and bleeding. So far, everything looks normal. The victim is making eye contact. 

“Ma’am, are you okay?” You kneel down and grasp her shoulder. 

“I’m not sure,” she replies. So she’s alert, but how alert? 

“I’m going to ask you some silly questions.” 

“Okay.” 

“What’s your name?” 

“Linda Jones.” 

“Hello, Ms. Jones, can you tell me where we are right now?” 

“We’re at the grocery store.” 

“And what day is it?” 

“Saturday” 

“Okay, good. Do you know what just happened?” 

“Well, not really. I was just standing there, then all of a sudden I was on the ground talking to a handsome man holding a bag of cheap generic Fruity Rings.” 

By now, you’ve ascertained that Ms. Jones is alert, because she’s answering questions and making eye contact like normal. She has no obvious bleeding or alarming skin signs. But, she can’t remember what just happened. In this case, we would say that Ms. Jones is alert and oriented to 3 (abbreviated A/Ox3). Because she is not oriented to event, she is classified as "altered." 

Side note: With geriatric patients, a ground-level fall can turn their bones into dust. Be cognizant of hip, elbow, or femur fractures, and head injuries. 

Is Ms. Jones Big Sick? Not currently. But, something is definitely wrong. 

Your next task is to identify potential causes of Ms. Jones’s fall. Start by thinking of HAM. (Have you noticed that we like mnemonics?) HAM stands for History, Allergies, Medications.  

Ask her: Do you have any medical problems that could have caused your fall? Do you have any allergies? What medication are you taking? These three questions will help you determine Big Sick vs. Little Sick. 

Right then, paramedics arrive. A jacked, handsome fireman with a deep voice wearing a bowtie asks you what’s going on. 

“Hey bro, Ms. Jones collapsed just a couple of minutes ago. She is alert and oriented x3, but does not remember the event. She has a history of blood sugar issues, is not allergic to anything that she knows of, and is currently on blood thinners.” 

The fire medic with chiseled abs and thick hair is blown away by your initial survey and turnover report. You both leap into the air and high five. Freeze-frame. You saved the day. 

TL:DR

• Initial assessment, or "across the room assessment" helps identify life-threatening presentations.

• Identify emergent conditions by assessing level of consciousness and airway, breathing, and circulation problems.

• Determine responsiveness by using AVPU mnemonic.

• If a patient is alert, ask orientation questions (person, place, time, event).

• Ask follow up questions regarding HAM – history, allergies, medications.

This is a good general overview of what to look for and how to assess between big sick and little sick. You are now trained to properly assess brain function. 

Bonus Assessment:

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