Whilst waiting for the doctor what other factors would you consider could cause a decrease in GCS?

Q. What other factors can cause decreasing levels of consciousness? Drag the factors from the list on the right to the appropriate column.

CAUSE

Seizure -Stroke is one of the commonest causes of seizure. In ischaemic stroke patients the prevalence of early seizures is between 3‐6%, whereas the risk is higher in patients with intracerebral haemorrhage  and is between 10‐16%.

Drugs – After a stroke many drugs (especially those with actions directly on the nervous system) can cause drowsiness and change in GCS. Painkillers are often a cause (e.g. opiates) but other problem drugs include sedatives (diazepam type drugs), anti-depressants (especially tricyclic antidepressants) and antispasmodic drugs (e.g. baclofen, tizanidine). It is important to introduce new drugs after a stroke at low doses and for nursing staff to be particularly on the look out for sedative effects.

Hypoglycaemia – (Usually in hypoglycaemia blood glucose < 2.5 mmol/l). Can cause a range of neurological symptoms and signs, transient or permanent, and importantly lead to hypoglycaemic coma (reduced GCS). Further hypoglycaemia can be a trigger for other causes of decreased GCS, e.g. low blood sugars can trigger a seizure. Hypoglycaemia is usually found in patients taking blood sugar lowering drugs (e.g. insulin) but can be seen in patients with sepsis, malignancy and liver failure.

Infection – Stroke patients are at risk of a wide number of infections. Stroke patients have less cerebral ‘reserve’ and severe infection is often clinically seen as confusion and agitation leading onto a deterioration in patients neurological symptoms and signs. Infection can also worsen pre-existing tendency to hypoglycaemia and hyponatraemia.

Head trauma/Subdural – After a stroke patients are at risk of falls and one potential complication of a fall is a head trauma with subsequent development of a sub-dural haematoma. Therefore sudden deterioration in the neurogical signs should prompt the question – \”has the patient fallen from the bed/chair since stroke onset and since the initial brain scan was performed?\”

Hyponatraemia – Hypoatraemia can cause decreasing levels of consciousness or seizures. Much more rarely tremor or hallucinations are associated with low sodium. It is not known how hypoatraemia causes worsening of conscious level.

Haemorrhagic transformation of an infarct – The sudden increase in pressure on the surrounding brain tissue can cause swelling and raised intracranial pressure leading to reduced levels of consciousness.

Increased urea due to dehydration – Dehydration is associated with increased urea (uraemia) – a toxin which causes widespread effects including confusion and reduced levels of consciousness.

NOT A CAUSE

Acutely blocked urinary catheter – An acutely blocked urinary catheter does not cause decreasing levels of consciousness.