Consciousness level assessment

Authors: Rednenko V.V.

Editor: Rednenko V.V.

Equipment for the practical skill:

• simulated patient or robotic simulator 
• patient bed

Clinical situation:

• Patient A., 65 years old, was admitted to the admission department of the central district hospital
• You are a doctor on duty, examine the patient and reveal the level of his consciousness

Order of the skill performance:

Preparatory stage:

• Put on PPE: medical gown, hat, mask, gloves

Maine stage:

• E - Check Eye response (four grades)
  • Look at the patient's eyes
  • Determine the possibility of the Eye response check. Eye response is not testable if the patient has severe trauma to the eyes, enucleation.
  • If the patient opens eyes spontaneously it's 4 points.
  • If the patient's eyes are closed, call the patient - If the patient opens eyes in response to voice it's 3 points. Not to be confused with the awakening of a sleeping person; such people receive a score of 4, not 3.
  • If the patient's eyes are closed after the call, give the patient  a pain stimulus, such as squeezing the lunula area of the person's fingernail or a trapezius squeeze), due to a grimacing effect. Eye opening in response to pain stimulus is 2 points.

• • Patient does not open eyes after a pain stimulus - it is 1 point.
• V - Check Verbal response (five grades)
  • Determine the possibility of the Verbal response check. Verbal response is not testable if the patient has intubation, deafness, language barrier, sedation from drugs, and paralysis.
  • Ask the patient questions about the person's name and age, where they are and why, the year, month, etc.
    • The person is oriented,  responds coherently and appropriately it is 5 points.
    • The person able to answer questions and responds to questions coherently but there is some disorientation and confusion, it is 4 points.
    • Inappropriate words. Random or exclamatory articulated speech, but no conversational exchange. Speaks words but no sentences. It is 3 points.
    • Incomprehensible sounds. Moaning but no words. It is 2 points.
    • No verbal response is 1 point
• M - Check Motor response (six grades)
  • Determine the possibility of the Verbal response check. Motor response is not testable if the patient has spinal cord injury, sedation from drugs, and paralysis.
  • Ask the patient to raise their hand (or any other simple movement). If the patietnt obeys commands (the person does simple things as asked) is 6 points.
  • If the patietnt dose not obey commands, give the patient  a pain stimulus (supraorbital pressure)

• • If the patient localises to pain  (purposeful movements towards painful stimuli; e.g., brings hand up beyond chin when supraorbital pressure applied) is 5 points
  • If the patient unable to lift hand past chin with supraorbital pain, pinche nailbed. If the patient pulls away the hand is Normal Flexion Flexion / Withdrawal from painful stimuli. It is 4 points.
  • Abnormal Flexion in response to pain. Abnormal flexion to a painful stimulus typically involves adduction of the arm, internal rotation of the shoulder, flexion of the elbow, pronation of the forearm and wrist flexion (known as decorticate posturing). It is 3 points.

• • Abnormal Extension in response to pain. The stimulus causes limb extension (abduction, internal rotation of shoulder, pronation of forearm, wrist extension) - decerebrate posture. It is 2 points.
  • No motor response. Lack of any motor response should raise suspicion for spinal cord injury. It is 1 point.

Final stage:

• Calculate the points (Е+V+M)
• Interpret the result
  • 3 (brain death),
  • 4-8 (coma),
  • 9-12 (sopor),
  • 12-13 (twilight consciousness or stupor), 
  • 14-15 (clear consciousness).