Why this matters: A change in consciousness is a sign of a potentially dangerous disturbance in the brain, airway, breathing, circulation, glucose, temperature, infection or toxic exposure. It may be the first clue to stroke, head injury, hypoxia, hypoglycaemia, poisoning, seizure or shock. EMTs need a rapid reproducible description, not a vague label such as “unconscious.” Assess the patient safely, correct reversible threats, repeat the examination and communicate the trend.
Learning outcomes
By the end of this lesson, the learner should be able to:
- Define consciousness, arousal, awareness, orientation, confusion, delirium, stupor and coma.
- Perform a rapid AVPU/ACVPU assessment and escalate when the response changes.
- Apply the Glasgow Coma Scale (GCS) by recording the best eye, verbal and motor responses separately.
- Recognise limitations caused by language, age, hearing, intubation, sedation, paralysis or injury.
- Assess pupils, limb movement, speech, glucose, oxygenation and other neurological clues.
- Build a time-critical differential diagnosis for altered consciousness using history and examination.
- Protect the airway, prevent aspiration and provide first-line emergency care within scope and local Uganda protocols.
- Document a baseline, interventions and repeat scores so deterioration is detected early.
1. What is consciousness?
Consciousness has two linked dimensions:
| Dimension | Meaning | How the EMT observes it |
|---|---|---|
| Arousal or wakefulness | The level of alertness and ability to respond to external stimulation. | Eyes open, response to voice, response to touch or painful stimulus, or no response. |
| Awareness or content | Ability to perceive, understand and interact with self and the environment. | Orientation, attention, memory, language, appropriate behaviour and command following. |
A person may be awake but confused, or have eyes closed yet respond appropriately to voice. Therefore “eyes open” is not the same as “normal consciousness,” and “not talking” is not automatically coma.
2. Key terms in level-of-consciousness assessment
| Term | Practical description | Emergency significance |
|---|---|---|
| Alert | Awake, attentive and interacting appropriately. | Still assess orientation and baseline; alertness alone does not exclude serious illness. |
| Lethargy | Drowsy, slow to respond, but arouses with gentle voice or light stimulation. | May reflect hypoxia, infection, metabolic disease, drugs, sleep deprivation or evolving neurological injury. |
| Obtundation | Reduced alertness; needs repeated or stronger stimulation and gives limited responses. | Requires urgent ABC and neurological assessment. |
| Stupor | Only vigorous stimulation produces a brief or purposeful response. | High aspiration and airway risk; treat as a time-critical emergency. |
| Coma | Unarousable state with no purposeful response to voice or physical stimulation. | Airway, breathing, circulation and cause must be managed urgently. |
| Confusion | Impaired thinking, attention or orientation; may fluctuate. | Often acute delirium from infection, hypoxia, glucose disturbance, drugs or organ failure. |
| Delirium | Acute fluctuating disturbance of attention and cognition. | It is a medical warning, not simply “bad behaviour” or psychiatric illness. |
| Syncope | Brief loss of consciousness from transient global cerebral hypoperfusion with spontaneous recovery. | Look for cardiac, bleeding, neurological, glucose and pregnancy-related causes. |
3. Why LOC is an emergency vital observation
- A small change from a person’s baseline can be the earliest sign of deterioration.
- Reduced consciousness compromises airway protection and increases aspiration risk.
- Hypoxia and hypercapnia can cause agitation, confusion, drowsiness and coma.
- Glucose abnormalities are common, rapidly reversible causes of altered behaviour or coma.
- Head injury, stroke, meningitis, seizure and poisoning may worsen while outward signs are subtle.
- A reproducible score makes it possible to recognise change during transport and handover.
“CONSCIOUSNESS = BRAIN + BODY + BASELINE”
Assess neurological function, search for systemic causes, and compare with the person’s normal state.
Assess neurological function, search for systemic causes, and compare with the person’s normal state.
4. When to assess level of consciousness
- During every primary survey and whenever the patient appears unwell.
- After trauma, a fall, assault, road crash, drowning, burn, electrocution or near-hanging.
- For seizure, fainting, sudden confusion, unusual behaviour, weakness or speech change.
- In suspected stroke, meningitis, sepsis, severe malaria, hypoxia or shock.
- After glucose, oxygen, naloxone, sedatives, anaesthesia, anticonvulsants or other drugs.
- For overdose, alcohol intoxication, carbon-monoxide exposure or unknown poisoning.
- In a child who is difficult to wake, feeding poorly, irritable, floppy or having abnormal movements.
- Before and after airway intervention, ventilation, transport movement or any clinical deterioration.
5. Safe approach before stimulating an altered patient
- Check scene safety, personal protective equipment and possible hazards such as traffic, electricity, fire, chemicals or violence.
- Look for medical alert jewellery, medication packets, trauma, blood, vomit, seizure clues or an unsafe position.
- Approach from the front, identify yourself and speak calmly. Avoid sudden shaking or frightening a confused patient.
- Protect the cervical spine when mechanism or examination suggests trauma; do not force the neck to assess consciousness.
- Do not give food, drink or oral medicine to a drowsy or uncooperative patient.
- Call for assistance early if the patient is not responding normally or cannot protect the airway.
6. Rapid AVPU/ACVPU assessment
AVPU is a rapid four-level responsiveness screen. Many emergency systems add C for new Confusion, creating ACVPU. Use the same sequence each time and document the best observed response.
| Level | Meaning | How to test | Example documentation |
|---|---|---|---|
| A – Alert | Awake and appropriately responsive. | Observe whether the patient attends, speaks and interacts normally. | “A: alert, follows conversation.” |
| C – Confusion | New disorientation or inattentive behaviour despite being awake. | Ask simple orientation and attention questions; compare with baseline. | “C: awake but newly confused; knows name, not place/time.” |
| V – Voice | Does not respond normally until spoken to or called. | Use a clear verbal command or the patient’s name; record the best response. | “V: opens eyes to voice, answers briefly.” |
| P – Pain/pressure | No response to voice but responds to an appropriate physical stimulus. | Use trained, safe stimulus; observe purposeful movement, withdrawal or abnormal posturing. | “P: localises pressure; no verbal response.” |
| U – Unresponsive | No eye, verbal or purposeful motor response. | Check breathing and pulse immediately; do not repeatedly apply painful stimuli. | “U: no response; abnormal breathing, resuscitation started.” |
AVPU is a screen, not a full neurological examination. A patient recorded as “A” may still have delirium, aphasia, stroke, intoxication or a dangerous medical cause.
7. Glasgow Coma Scale: purpose and structure
The Glasgow Coma Scale (GCS) quantifies the patient’s best observed response in three components: Eye opening (E), Verbal response (V) and Motor response (M). The total ranges from 3 to 15, but the component scores are more informative than the total alone. Always write the components, for example GCS E3 V4 M6 = 13.
| Component | Score range | What it measures |
|---|---|---|
| Eye opening (E) | 1–4 | Wakefulness and response of the eyes to spontaneous activity, voice or pressure. |
| Verbal response (V) | 1–5 | Orientation, conversation, words, sounds or absence of speech. |
| Motor response (M) | 1–6 | Ability to obey commands, localise, withdraw, flex, extend or show no movement. |
| Total | 3–15 | Summary only; component pattern and trend must accompany it. |
8. GCS eye-opening response
| Score | Response | How to interpret |
|---|---|---|
| E4 | Spontaneous | Eyes open without being asked or stimulated. |
| E3 | To sound/voice | Eyes open after the patient is called or spoken to. |
| E2 | To pressure | Eyes open only after an appropriate physical stimulus. |
| E1 | None | No eye opening despite appropriate stimulation. |
Do not score eye opening from eyelid swelling, facial trauma or a sedated/intubated patient without recording the limitation. If one eye is injured and the other opens, document the injury and use the testable eye response according to local GCS training.
9. GCS verbal response
| Score | Response | Testing approach |
|---|---|---|
| V5 | Orientated | Converses appropriately and identifies person, place and time or situation. |
| V4 | Confused | Converses but is disoriented, inattentive or gives inconsistent answers. |
| V3 | Inappropriate words | Uses recognisable words that are unrelated or not conversational. |
| V2 | Incomprehensible sounds | Moans, groans or sounds without recognisable words. |
| V1 | None | No audible verbal response. |
Consider language, hearing, aphasia, developmental level, intoxication, facial injury and an endotracheal tube. A person who cannot speak because of intubation should not be mislabelled as V1; record the component as not testable or use the locally approved notation.
10. GCS motor response
| Score | Response | Meaning |
|---|---|---|
| M6 | Obeys commands | Performs a simple, appropriate movement when asked, such as showing two fingers or lifting an arm. |
| M5 | Localises pressure | Purposefully reaches toward and attempts to remove the stimulus. |
| M4 | Withdraws | Pulls the limb away but does not purposefully locate the stimulus. |
| M3 | Abnormal flexion | Flexor posturing in response to stimulation; document the side and pattern. |
| M2 | Abnormal extension | Extensor posturing; a severe sign requiring urgent escalation. |
| M1 | None | No motor response to the tested stimulus. |
11. How to assess GCS in sequence
- Observe first: note spontaneous eye opening, speech and purposeful movement before touching the patient.
- Talk normally: introduce yourself, ask the patient to open their eyes, state their name and follow a simple command.
- Use voice progressively: increase volume only enough to obtain a response; avoid shouting into the ear.
- Ask orientation questions: person, place, time and situation, using language the patient understands.
- Test commands: use a simple, non-painful command such as “show me two fingers” or “lift your arm.” Test both sides when weakness is suspected.
- Apply a trained stimulus only if required: use an approved central or peripheral pressure technique, avoid injured areas and never cause unnecessary harm.
- Record the best response: write E, V and M separately, the total, time, side differences and factors that limit testing.
12. GCS examples
| Patient response | Score | Correct report |
|---|---|---|
| Eyes open to voice, confused conversation, obeys command | 3 + 4 + 6 = 13 | GCS E3 V4 M6 = 13 |
| Eyes spontaneous, orientated, localises pressure only | 4 + 5 + 5 = 14 | GCS E4 V5 M5 = 14 |
| No eye opening, incomprehensible sounds, withdraws | 1 + 2 + 4 = 7 | GCS E1 V2 M4 = 7 |
| Eyes open to voice, no speech because intubated, obeys command | 3 + NT + 6 | Record E3 V-NT M6; explain intubation rather than inventing a total. |
| Eyes closed by swelling, speaks orientated, obeys command | NT + 5 + 6 | Record eye limitation and component scores; do not force an inaccurate total. |
13. GCS interpretation and escalation
Lower scores generally indicate more severe impairment, but there is no safe practice of looking only at the total. A fall of two points, a new unequal response, a new pupil abnormality or a change from obeying commands to withdrawing may represent deterioration even when the total remains above a commonly quoted threshold.
| Pattern | Clinical meaning | Action |
|---|---|---|
| GCS 15 but new confusion | Awake with abnormal content of consciousness. | Search for hypoxia, glucose, infection, stroke, drugs, pain and baseline causes. |
| GCS 13–14 after trauma | Abnormal neurological state until assessed and trended. | Protect airway and spine as indicated; urgent clinical review and transport. |
| GCS 8 or less | Severe impairment; airway protection may be compromised. | Immediate advanced help, airway/ventilation plan and urgent transport per protocol. |
| Any rapid decline | Potential expanding intracranial, toxicological, respiratory or metabolic emergency. | Repeat ABCDE, correct reversible threats and escalate immediately. |
Important: “GCS 8, intubate” is not a substitute for clinical judgement or local scope. Airway decisions depend on breathing, protective reflexes, cause, skills, equipment and medical control.
14. Consciousness assessment is more than GCS
GCS measures observable responsiveness. It does not by itself diagnose the cause, assess memory, detect every focal deficit or replace ABCDE. Add the following to every altered-consciousness assessment:
| Domain | What to examine | Why it matters |
|---|---|---|
| Airway | Snoring, gurgling, vomit, secretions, tongue position, gag/cough and ability to handle saliva. | A drowsy patient may obstruct or aspirate despite a measurable GCS. |
| Breathing | Rate, depth, effort, oxygen saturation, symmetry, carbon-dioxide risk and abnormal pattern. | Hypoxia and hypercapnia both alter consciousness. |
| Circulation | Pulse, blood pressure, skin, capillary refill, temperature and bleeding. | Shock and poor cerebral perfusion cause confusion, collapse and coma. |
| Disability | AVPU/GCS, pupils, glucose, seizure activity, speech and limb movement. | Identifies reversible and focal neurological threats. |
| Exposure | Temperature, rash, trauma, needle marks, medication patches, bites and environmental clues. | Reveals infection, poisoning, heat/cold illness or injury. |
15. Pupil assessment
| Feature | How to assess | Possible significance |
|---|---|---|
| Size | Compare right and left in ambient light. | Unequal size may be baseline, eye injury, drug effect or neurological compression. |
| Equality | Note anisocoria and whether it is new. | A new large unequal pupil after trauma is an emergency warning. |
| Reaction | Shine light from the side and observe constriction and re-dilation. | Sluggish or absent reaction may indicate ocular, drug, brainstem or severe metabolic disease. |
| Shape | Round or irregular; inspect for trauma or surgery. | Irregularity can limit interpretation. |
| Trend | Repeat and document changes with time. | A changing pupil pattern can signal neurological deterioration. |
Do not shine bright light into a patient with obvious eye trauma or delay airway care for a pupil examination. Record “equal and reactive,” “unequal,” “fixed,” “sluggish,” or the exact observed pattern rather than a vague “pupils normal.”
16. Limb movement, strength and symmetry
- Ask the awake patient to smile, show teeth, raise both arms and squeeze both hands if safe.
- Compare left and right movement; note drift, weakness, neglect, tremor or abnormal posturing.
- Observe spontaneous movement before applying pressure. Purposeful localisation is different from simple withdrawal.
- In trauma, maintain spinal precautions and do not force movement that could worsen injury.
- A new one-sided weakness, facial asymmetry or speech problem activates a stroke pathway even when the GCS is 15.
17. Speech and language
| Finding | Possible interpretation | Clarifying question |
|---|---|---|
| Dysarthria | Slurred or poorly articulated speech from weakness, intoxication or neurological disease. | Is this new? Any facial droop, limb weakness or last-known-well time? |
| Aphasia | Difficulty understanding or producing language despite wakefulness. | Can the patient follow a simple command or name an object? |
| Confused answers | Disorientation, delirium, intoxication or language barrier. | What is the patient’s baseline language and orientation? |
| Incomprehensible sounds | Severe reduction in verbal response or communication barrier. | Check hearing, language, airway, pain and GCS limitations. |
| Sudden silence | Possible seizure, airway deterioration, stroke or exhaustion. | Reassess breathing and responsiveness immediately. |
18. Blood glucose in altered consciousness
Check capillary glucose early in confusion, seizure, collapse or reduced consciousness. Hypoglycaemia is rapidly reversible; severe hyperglycaemia can signal DKA or HHS. A “normal” glucose does not rule out stroke, hypoxia, poisoning, infection, head injury or seizure.
| Finding | Immediate implication | Safety action |
|---|---|---|
| Low glucose and able to swallow | Likely symptomatic hypoglycaemia. | Give fast carbohydrate under protocol, repeat glucose and observe for recurrence. |
| Low glucose and unable to swallow | Severe hypoglycaemia with aspiration risk. | Nothing by mouth; airway support and authorised IV dextrose/glucagon pathway. |
| High glucose with dehydration/vomiting | Possible DKA or HHS. | ABCs, monitor, urgent transport and no unsupervised insulin. |
| Unexpected result | Sampling or meter error may coexist with another emergency. | Repeat safely while treating the clinical condition. |
19. Oxygenation, ventilation and LOC
Assess altered consciousness alongside respiratory observations. Hypoxaemia may cause agitation, restlessness, confusion, cyanosis and coma. Hypercapnia may cause headache, flushed skin, drowsiness, asterixis or reduced consciousness. A pulse oximeter can remain normal in hypoventilation or carbon-monoxide exposure, so rate, depth, chest movement and mental status remain essential.
20. Seizure and postictal assessment
- Protect the patient from injury and time the event; do not restrain forcefully or insert objects into the mouth.
- After convulsions, reassess airway, breathing, glucose, temperature, pupils and focal deficits.
- Postictal drowsiness can be expected, but a prolonged or worsening reduction in consciousness requires urgent evaluation.
- Ask witnesses about onset, movements, eye deviation, incontinence, tongue injury, duration and return to baseline.
- Consider hypoglycaemia, eclampsia, infection, head injury, poisoning and stroke when the seizure is new or atypical.
21. Common causes of altered consciousness
| Category | Examples | Clues to seek |
|---|---|---|
| Oxygen/ventilation | Airway obstruction, asthma, pneumonia, pulmonary oedema, overdose or respiratory failure. | Abnormal RR, cyanosis, noisy breathing, poor air entry, low or misleading SpO2. |
| Glucose/metabolic | Hypoglycaemia, DKA/HHS, sodium disturbance, renal/liver failure, severe dehydration. | Diabetes, vomiting, thirst/polyuria, medication changes, uremic or hepatic signs. |
| Infection | Meningitis, encephalitis, sepsis, severe malaria or pneumonia. | Fever or hypothermia, rash, neck stiffness, rigors, shock, exposure/travel. |
| Neurological | Stroke, intracranial haemorrhage, seizure, tumour, raised intracranial pressure. | Focal deficit, severe headache, pupil change, trauma, seizure or unequal movement. |
| Toxicological | Opioids, alcohol, sedatives, pesticides, carbon monoxide and unknown substances. | Containers, odour, pinpoint or dilated pupils, respiratory depression, scene clues. |
| Trauma/temperature | Head injury, spinal injury, heat stroke or hypothermia. | Mechanism, wounds, bleeding, body temperature and environmental exposure. |
| Circulatory | Shock, dysrhythmia, myocardial infarction or syncope. | Weak pulse, hypotension, chest pain, palpitations, bleeding or poor perfusion. |
| Psychiatric/functional | Severe mental-health crisis or functional symptoms. | Diagnosis only after dangerous medical and neurological causes are assessed. |
22. Differential mnemonic: AEIOU-TIPS
Use mnemonics to widen thinking, not to replace clinical judgement.
| Letter | Cause group | Examples |
|---|---|---|
| A | Alcohol / acidosis | Alcohol toxicity, DKA, lactic acidosis, renal failure. |
| E | Epilepsy / electrolytes / endocrine | Seizure/postictal state, sodium disturbance, adrenal or thyroid crisis. |
| I | Insulin | Hypoglycaemia or medication error. |
| O | Oxygen / overdose | Hypoxia, hypercapnia, opioids, sedatives or carbon monoxide. |
| U | Uraemia | Advanced renal failure and metabolic toxins. |
| T | Trauma / temperature | Head injury, heat stroke or hypothermia. |
| I | Infection | Meningitis, encephalitis, sepsis, malaria. |
| P | Psychiatric / poisoning | Functional symptoms only after medical assessment; toxic exposures. |
| S | Stroke / shock | Intracranial event, haemorrhage, low perfusion or dysrhythmia. |
23. History for an altered patient: SAMPLE and last-known-well
| History element | Questions for the patient, family or witnesses |
|---|---|
| Signs and symptoms | What changed? Headache, fever, seizure, weakness, speech change, vomiting, chest pain or breathing difficulty? |
| Allergies | Any drug, food or environmental allergy? Was there swelling or exposure? |
| Medications | Insulin, antihypertensives, sedatives, opioids, anticonvulsants, anticoagulants or recent dose change? |
| Past history | Diabetes, epilepsy, stroke, renal/liver disease, HIV, pregnancy, psychiatric illness or previous episodes? |
| Last oral intake | When did the patient last eat, drink alcohol or take medicines? |
| Events | What happened immediately before the change? Fall, assault, illness, exertion, exposure or witnessed seizure? |
| Last-known-well | When was the patient last definitely normal, and who saw them? |
| Baseline function | Normal speech, memory, mobility, hearing, language and behaviour? |
24. Examine the scene for clues
- Medication packets, insulin pens, glucose gel, alcohol, pesticides, charcoal stoves or chemical containers.
- Blood, vomit, faeces, urine, tongue injury, wet clothing or a postictal environment.
- Trauma, fall height, broken furniture, helmet, weapons or a witnessed assault.
- Fever, rash, neck stiffness, sick contacts, mosquito exposure or recent treatment for infection.
- Evidence of carbon monoxide: multiple people affected, enclosed space, charcoal or generator use, headache and confusion.
- Family observations of new behaviour, missed medicines, poor feeding or progressive drowsiness.
25. Immediate ABCDE response
- Airway: open and protect it; remove only visible obstruction, suction when trained and prepare an airway adjunct if indicated.
- Breathing: assess rate, effort, oxygenation and chest movement; provide oxygen or ventilation support according to protocol.
- Circulation: check pulse, blood pressure, skin, bleeding and perfusion; obtain access if trained and authorised.
- Disability: AVPU/ACVPU, GCS, pupils, glucose, seizure and focal neurological signs.
- Exposure: temperature, trauma, rash, medication patches, injection marks and environmental causes while maintaining dignity and warmth.
- Transport and escalation: request advanced help early, pre-alert the receiving facility and repeat the LOC assessment during movement.
26. Airway protection and aspiration prevention
| Situation | Position/support | Do not do |
|---|---|---|
| Awake but confused | Keep upright or position of comfort; supervise continuously. | Do not leave alone or assume confusion is psychiatric. |
| Drowsy but breathing normally | Open airway, consider lateral recovery position if no contraindication and monitor. | Do not give oral fluids, food or tablets. |
| Unresponsive but breathing | Protect airway, suction as needed, lateral position with spinal precautions when appropriate. | Do not repeatedly shake or place objects in the mouth. |
| Not breathing normally | Resuscitation pathway, CPR/AED and ventilation support. | Do not delay for a full GCS score. |
| Possible spinal trauma | Manual stabilisation and trauma airway manoeuvre per training. | Do not hyperextend the neck unnecessarily. |
27. Altered consciousness after trauma
Assume a potentially significant head or spinal injury until assessed. Obtain the mechanism, loss of consciousness, amnesia, vomiting, seizure, anticoagulant use and time course. Control external bleeding, maintain oxygenation and perfusion, prevent hypothermia, repeat pupils/GCS and follow the trauma referral pathway. A patient who “wakes up” after a head injury still requires evaluation.
28. Altered consciousness and stroke
- Record last-known-well time and use the approved stroke screen for facial droop, arm weakness and speech disturbance.
- Check glucose because hypoglycaemia can mimic stroke, but do not delay stroke referral when focal deficits persist.
- Look for gaze deviation, neglect, unequal pupils, severe headache, vomiting or sudden collapse.
- Keep the patient NPO until swallowing is assessed; transport rapidly and pre-alert the receiving facility.
29. Delirium versus dementia
| Feature | Delirium | Dementia or chronic cognitive impairment |
|---|---|---|
| Onset | Sudden, hours to days. | Usually gradual over months or years. |
| Course | Fluctuates, often worse at night. | Progressive or relatively stable over a short period. |
| Attention | Markedly impaired or difficult to sustain. | May be relatively preserved early. |
| Cause | Often infection, hypoxia, glucose, medication, dehydration or organ failure. | Underlying neurocognitive disease; acute illness can cause superimposed delirium. |
| EMT response | Urgently search for a medical cause and compare with baseline. | Do not assume a new change is “just dementia”; seek collateral history. |
30. Consciousness in children
- Ask the caregiver what is normal for the child’s alertness, eye contact, speech, feeding and movement.
- Use age-appropriate commands; a preverbal child may show purposeful interaction without adult speech.
- Check glucose when altered consciousness, seizure, poor feeding or severe illness is present, following the paediatric protocol.
- Assess breathing, oxygenation, temperature, hydration, fontanelle when age-appropriate, pupils and focal movement.
- Do not frighten or repeatedly painful-stimulate a child; use gentle voice and observe spontaneous responses first.
- Any unresponsive child, repeated seizure, stiff neck, bulging fontanelle, severe dehydration or abnormal breathing requires urgent escalation.
31. Pregnancy and postpartum altered consciousness
Consider eclampsia, severe hypertension, haemorrhage, hypoglycaemia, thromboembolism, infection, stroke, anaesthetic/drug effects and metabolic illness. Ask gestational age, antenatal history, blood pressure concerns, headache, visual symptoms, abdominal pain, bleeding and seizure history. Protect the airway, position to support maternal circulation, follow the obstetric emergency protocol and arrange urgent transport.
32. Older adults and communication barriers
| Challenge | Risk | Good practice |
|---|---|---|
| Hearing loss | Patient may appear unresponsive to voice. | Face the patient, speak clearly, use hearing aids and confirm with family. |
| Language difference | Incorrectly low verbal score or mistaken confusion. | Use an interpreter or trusted bilingual person; document the limitation. |
| Dementia baseline | Chronic disorientation may be mistaken for new delirium. | Ask caregivers what changed and when. |
| Stroke/aphasia | Cannot express answers despite understanding. | Test comprehension and commands; record aphasia rather than V1. |
| Intubation or facial injury | Verbal/eye components may be untestable. | Use NT notation and describe the limitation. |
33. Sedation, paralysis and other GCS limitations
- Sedatives, analgesics, alcohol and anaesthetics suppress responses; record the drug, dose if known and time.
- Neuromuscular blockers, spinal cord injury or limb paralysis can reduce motor responses without global coma.
- Intubation, tracheostomy, deafness, aphasia, language barrier and developmental disability affect verbal testing.
- Facial swelling, eye injury or a dressing may prevent eye opening; record “not testable,” not an invented low score.
- Hypothermia, hypoglycaemia, shock and hypoxia may change the score; correct reversible threats and repeat.
34. Monitoring frequency and trending
| Patient state | Monitoring approach | Escalate for |
|---|---|---|
| Alert, stable, no red flags | Baseline AVPU/GCS, pupils, glucose when indicated and repeat if symptoms change. | New confusion, drowsiness, headache, weakness or abnormal vital signs. |
| Confused or intoxicated | Frequent repeat LOC, airway, breathing, glucose and temperature; continuous supervision. | Falling response, vomiting, hypoventilation, seizure or unsafe behaviour. |
| Post-seizure or head injury | Serial GCS components, pupils, vital signs and focused neurological examination. | Two-point fall, new focal deficit, unequal pupil or repeated vomiting. |
| Unresponsive | Continuous ABC observation and repeated response checks while supporting airway/breathing. | Any abnormal breathing, absent pulse, loss of airway protection or deterioration. |
35. Documentation template
| Record | Example |
|---|---|
| Baseline and time | “14:10, family reports normally alert and independent; last known well 13:30.” |
| AVPU/ACVPU | “C: awake but inattentive and newly disoriented.” |
| GCS components | “E3 V4 M6 = 13; follows commands symmetrically.” |
| Pupils | “3 mm equal and reactive bilaterally; no new anisocoria.” |
| Vitals and glucose | “RR 28, SpO₂ 89% room air, BP 92/58, CBG 4.8 mmol/L, temperature 39.1°C.” |
| Interventions | “Airway repositioned, oxygen applied per protocol, IV access requested, cooling and urgent transport.” |
| Trend | “At 14:25 E2 V3 M5 = 10; increasing drowsiness; receiving facility pre-alerted.” |
36. Clinical scenarios for EMT practice
Scenario 1 – hypoglycaemia: A known diabetic is sweaty, confused and obeys only simple commands. CBG is 2.8 mmol/L. Protect the airway, assess swallowing, treat the low within protocol and repeat the GCS and glucose. Do not discharge after one improved reading if the medicine or cause is uncertain.
Scenario 2 – head injury: A motorcycle passenger initially has E4 V5 M6 and then becomes E3 V4 M5 with vomiting. This is a neurological decline even though the total is still 12. Protect the spine and airway, repeat pupils/vitals and transport urgently.
Scenario 3 – opioid overdose: The patient is unresponsive, RR 5/min, pupils pinpoint and glucose normal. Support ventilation and airway, follow the authorised naloxone pathway and continue monitoring because the drug may outlast the reversal.
Scenario 4 – stroke with aphasia: The patient is alert, understands commands and has right-arm weakness but cannot produce words. Do not score verbal response as V1 without noting aphasia; record the limitation and activate the stroke pathway.
Scenario 5 – febrile child: A 3-year-old is lethargic, has fever, stiff neck and a new seizure. Check glucose and breathing, protect the airway, avoid oral intake, manage the seizure according to protocol and arrange immediate transfer.
Scenario 6 – carbon monoxide: Two family members are drowsy in a room with a charcoal stove and both have normal pulse-oximeter values. Suspect CO exposure, move to fresh air without endangering rescuers, provide oxygen according to protocol and obtain urgent medical care.
37. Common mistakes to avoid
- Writing only “unconscious” without AVPU/GCS components, pupils, glucose and airway status.
- Accepting a family statement of “sleeping” without checking response and breathing.
- Applying painful stimulation before looking, speaking and checking reversible threats.
- Assigning a verbal score of 1 when aphasia, language difference, intubation or hearing loss explains the lack of speech.
- Using the GCS total without identifying which component changed.
- Assuming intoxication is the diagnosis before excluding hypoglycaemia, trauma, stroke, infection and hypoxia.
- Giving oral fluids or medication to a drowsy patient.
- Failing to repeat LOC after glucose, oxygen, antidote, seizure, movement or transport.
- Forgetting the last-known-well time and the patient’s usual baseline.
38. EMT LOC checklist
| Assess | Record | Act |
|---|---|---|
| Scene, airway and breathing | Time and baseline | Open/protect airway |
| AVPU/ACVPU | GCS E, V, M and total/NT | Support oxygenation/ventilation |
| Pupils and limb symmetry | Glucose, vital signs and temperature | Correct reversible threats within protocol |
| Trauma, seizure, poison and infection clues | Last-known-well and witness history | Escalate, pre-alert and transport |
| Trend after intervention | Response to treatment and repeat time | Never leave a deteriorating patient unattended |
39. Revision questions
- Define arousal and awareness.
- Distinguish lethargy, obtundation, stupor and coma.
- What does AVPU stand for?
- Why is ACVPU useful?
- What are the three GCS components?
- What is the score for spontaneous eye opening?
- What is the difference between localising and withdrawing?
- Why must GCS components be documented separately?
- What factors make verbal scoring not testable?
- What does a falling GCS after trauma suggest?
- List six reversible causes of altered consciousness.
- Why should glucose be checked early?
- Why can pulse oximetry be misleading in carbon-monoxide exposure?
- What pupil changes require urgent escalation?
- How do you protect the airway of an unresponsive breathing patient?
- Why should oral intake be withheld in reduced consciousness?
- What questions establish last-known-well?
- How can delirium differ from dementia?
- What extra considerations apply to a child?
- Why is intoxication a diagnosis of exclusion in an altered patient?
- What signs suggest respiratory failure as the cause?
- What is the role of the family or witness history?
- When should advanced help be requested?
- What should be repeated after treatment?
- Write a complete example of an altered-consciousness handover.
40. Key takeaways
- Describe responsiveness precisely with AVPU/ACVPU and GCS rather than using “unconscious” alone.
- Record GCS as E, V and M components, identify non-testable factors and trend the score over time.
- Always check airway, breathing, circulation, glucose, pupils and focal neurological signs.
- Hypoxia, hypoglycaemia, shock, trauma, seizure, infection and poisoning are time-critical possibilities.
- Protect the airway and withhold oral intake whenever swallowing and airway protection are unsafe.
- Do not blame alcohol, dementia or psychiatric illness until dangerous medical causes have been assessed.
- A changing level of consciousness is deterioration until proven otherwise; escalate early and transport urgently.
41. References and further reading
- Altered Level of Consciousness – supplied teaching slides (SlideShare).
- Resuscitation Council UK: ABCDE approach and ACVPU.
- University of Glasgow: Glasgow Coma Scale assessment.
- WHO/ICRC Basic Emergency Care: AVPU and altered mental status.
- WHO: diagnostic tests in children with seizures or altered consciousness.
- Merck Manual Professional: overview of coma and impaired consciousness.
- Merck Manual Professional: assessing mental status.
Scope note: This lesson supports EMT learning and examination preparation. Follow current Uganda Ministry of Health, ambulance-service, facility and medical-control protocols for airway devices, glucose rescue, seizure medicines, antidotes, trauma immobilisation, paediatric care and transport decisions.