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Neurological assessment 1 - Assessing level of consciousness

8 July, 2008

This article, the first in a four-part series on neurological assessment, describes assessment of level of consciousness. Click here to download the PDF of this article, with graphics included. Click here for more articles in our Practical Procedures series. Author Phil Jevon, PGCE, BSc, RGN, is resuscitation officer/clinical skills lead, honorary clinical lecturer, Manor Hospital, Walsall. Neurological assessment is essential in the assessment of the acutely ill patient (NICE, 2007; Resuscitation Council UK, 2006). As a problem with airway, breathing or circulation can lead to altered level of consciousness, initial priorities include ensuring a clear airway, and adequate breathing and circulation.

Consciousness
Consciousness is defined as the state of being aware of physical events or mental concepts. Conscious patients are awake and responsive to their surroundings (Marcovitch, 2005).

The level of consciousness has been described as the degree of arousal and awareness. A manifestation of altered consciousness implies an underlying brain dysfunction. Its onset may be sudden, for example following an acute head injury, or it may occur more gradually, such as in hypoglycaemia. Causes of altered consciousness A range of situations can lead to altered consciousness. These include: profound hypoxaemia; hypercapnia; cerebral hypoperfusion; stroke; convulsions; hypoglycaemia; recent administration of sedatives or analgesic drugs; drug overdose; subarachnoid haemorrhage; and alcohol intoxication (Resuscitation Council UK, 2006; Wyatt et al, 2006). ABCDE assessment The Resuscitation Council UK (2006) recommends the ABCDE approach:

Airway; Breathing; Circulation; Disability; Exposure.

Evaluating disability involves assessing the level of consciousness (using the AVPU scale), pupillary assessment, and sometimes the Glasgow Coma Scale. Staff caring for a patient with a head injury admitted for observation should all be able to assess:

Respiratory rate; heart rate; temperature; blood pressure; blood oxygen saturation; Glasgow Coma Scale (GCS); Pupil size and reactivity; Limb movements (NICE, 2007).

Level of consciousness It is not possible to directly assess the level of consciousness - it can only be assessed by observing the patients behavioural response to different stimuli. During the initial rapid assessment of the critically ill patient, it is helpful to use the AVPU scale, with an examination of the pupils; the GCS should be used in the full assessment (Smith, 2003). NICE (2007) recommends using GCS to assess all patients with head injuries. Before assessment, ascertain the patients acuity of hearing, medical history and any indications that may affect level of consciousness. AVPU

The AVPU scale is a quick and easy method to assess level of consciousness. It is ideal in the initial rapid ABCDE assessment:

Alert; Responds to voice; Responds to pain; Unconscious (RCUK, 2006).

AVPU is incorporated into many early-warning score systems for critically ill patients, as it is simpler tool than GCS, but is not suitable for long-term observation. The procedure

Explain the procedure to the patient. Assess the level of consciousness using the AVPU scale; if fully awake and talking to you, they are A (alert). If they respond but appear confused, try to establish whether this is a new or a long-standing problem; causes of recent onset confusion include neurological pathology and hypoxia. If the patient is not fully awake, check if they respond to your voice, for example by opening their eyes, speaking or moving; if they do, they are V (responds to voice). If the patient does not respond to voice, administer a painful stimulus such as a trapezium squeeze (Fig 1) and check for a response (eye opening, verbal such as moaning, or movement); if there is a response, they are P (responds to pain). Those who do not respond are U (unresponsive). Record the AVPU reading on the patients observation chart (Fig 2). The patient may need to be in the lateral position to help keep the airway patent; oxygen may need to be administered (Fig 3). Try to establish a cause of altered consciousness. Check the medical history and presenting complaint. Check for a medical alert bracelet or similar (Fig 4). Check the medication chart (Fig 5) as some medications can affect consciousness. To further establish the cause, perform bedside glucose assessment to exclude hypoglycaemia and hyperglyaemia (Fig 6). Check for evidence of alcohol intake, such as a smell on the breath. Check for signs of a head injury.

Professional responsibilities This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols. References Marcovitch, H. (2005) Blacks Medical Dictionary. London: Black.

NICE (2007) Head injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults. www.nice.org.uk Resuscitation Council (UK) (2006) Advanced Life Support. www.resus.org.uk Smith, G. (2003) ALERT Acute Life-Threatening Events Recognition and Treatment. Portsmouth: University of Portsmouth. Wyatt, J. et al (2006) Oxford Handbook of Emergency Medicine. Oxford: Oxford University Press.

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Measuring Consciousness
Researchers are identifying distinctive brain activity patterns that can be used to monitor patients under anesthesia and assess consciousness in vegetative patients. By Dan Cossins | April 17, 2013

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Electrodes are held in place with a cap during an EEG recordingWIKIMEDIA, CHRIS HOPEGeneral anesthesia has transformed surgery from a ghastly ordeal to a

procedure in which the patient feels no pain. Despite its widespread use, however, little is known about how anesthesia produces loss of consciousnessa blind spot brought into sharp focus by the fact that patients still occasionally wake up during surgery. But over the past 5 years, researchers have made significant progress in understanding what happens in the brain as consciousness departs and returns. Peering into the anesthetized brain with neuroimaging and electroencephalograph (EEG) recordings, scientists have found evidence to support the integrated-information theory, which holds that consciousness relies on communication between different brain areas, and fades as that communication breaks down. EEG studies have also revealed distinctive brain wave patterns that signal when consciousness is lost and regained, offering easily identifiable markers for this impairment of communication. Though many questions remain, advances in brain activity monitoring promise to shed light the neural basis of consciousness, and to eradicate the nightmare of mid-surgery awakenings. Whats more, by

combining EEGs with magnetic brain stimulation, researchers may be able to measure consciousness and track recovery in unresponsive patients diagnosed as vegetative, who in recent years have been shown to sometimes have higher levels of consciousness than previously realized.

The asynchronous brain


To tease out neural markers of consciousnessor more precisely, the loss of consciousnessa group led by Patrick Purdon, an instructor of anesthesia and bioengineer at Harvard Medical School and Massachusetts General Hospital (MGH), recently looked at brain activity in epileptic patients as they received increasing doses of the commonly used anesthesia drug propofol in preparation for surgery. The purpose of the surgery was to remove electrodes that had previously been implanted in the patients brains to monitor seizures. But before they were taken out, the electrodes enabled the researchers to study the activity of individual neurons in the cortex, in addition to large-scale brain activity from EEG recordings. In a Proceedings of the National Academy of Sciences paper published last November, the researchers reported that a few seconds before consciousness was lostas indicated by the patients response to sound stimulithe EEG revealed the onset of low-frequency (>1 hertz), or slow wave, oscillations. Meanwhile, the implanted electrodes showed that the firing of ensembles of individual neurons in different but nearby regions of the cortex was interrupted every few hundred millisecondsan unusual pattern, as cortical neurons usually fire regularly and without interruption. The slow oscillations, the team realized, were occurring asynchronously across the cortex, meaning that when one set of neurons in one area was firing, another set of neurons in a nearby area was often silent. This pattern likely disrupts the passage of information between cortical areas, something that has been associated with loss of consciousness by several studies over the last few years. The importance of communication between discrete groups of neurons, both within the cortex and across brain regions, is analogous to a band playing music, said George Mashour, a neuroscientist and anesthesiologist at the University of Michigan, Ann Arbor. You need musical information to come together either in time or space to really make sense, he said. Consciousness and cognitiv e activity may be similar. If different areas of the brain arent in synch or if a critical area that normally integrates cognitive activity isnt functioning, you could be rendered unconscious.

Monitoring consciousness
Earlier this year, Purdon and colleagues were able to discern a more detailed neural signature of loss of unconsciousness, this time by using EEG alone. Monitoring brain activity in healthy patients for 2 hours as they underwent propofol-induced anesthesia, they observed that as responsiveness fades, high-frequency brain waves (1235 hertz) rippling across the cortex and the thalamus were replaced by two different brain waves superimposed on top on one another: a low-frequency (<1 hertz) wave and an alpha frequency (812 hertz) wave. These two waves pretty much come at loss of consciousness, said Purdon. At first, as the patients were sedated, the alpha waves peaked when the low-frequency waves were at their lowest pointa pattern the researchers termed the peak-trough. When the patients stopped responding altogether, that relationship flipped: the alpha and low-frequency waves peaked at the same time, known as the peak-max pattern. Then, as the patients began to respond again, the peak-trough returned. We now have the ability to be certain that someone is unconscious by finding that peak-max pattern, said Purdon. And we can predict when they can recover consciousness by looking at this peak-trough pattern. The patterns are reliable and distinctive enough to have immediate application in the clinic, added coauthor Emery Brown, an anesthesiologist at MGH and a neuroscientist at the Massachusetts

Institute of Technology. Weve started to teach our anesthesiologi sts how to read this signature on the EEG to improve upon current methods for monitoring patients during surgery, he said. These beautifully choreographed series of changes are really promising, said Robert Pearce of the University of Wisconsin, an anesthesiologist and neuroscientist who studies the neurophysiology of consciousness. Its very clear that these [EEG patterns] are associated with consciousness levels.

A universal measure?
Anesthesia is not the only state in which consciousness is lost, of course. So could the same markers be used to assess the level of consciousness in patients in a vegetative state? Not necessarily, said Mashour, because the two states are distinct and may result from different neural mechanisms. But, he added, the more we focus on measuring consciousnessrather than the effects of anesthetics, per sethe more versatile our future monitors will be. With this goal in mind, Pearce and University of Wisconsin neuroscientist Giulio Tononithe originator and leading proponent of the integrated-information theory of consciousnesshave combined EEG recordings with transcranial magnetic stimulation (TMS) to measure the gradual breakdown of connectivity between neural networks during natural REM sleep and anesthesia, as well as in braininjured, unresponsive patients. Using an electromagnetic coil to activate neurons in a small patch of the human cortex, then recording EEG output to track the propagation of those signals to other neuronal groups, the researchers can measure the connectivity between collections of neurons in the cortex and other brain regions. Its a perturbational approach, said Pearceyou can directly to activate neurons in one part of the cortex and see how other parts respond. If the integrated-information theory holds true, the researchers will be able to use their strategy to gauge levels of consciousness even in a damaged brain, which may not exhibit the same EEG markers of consciousness as an intact, anesthetized brain. Indeed, Tononi and Marcello Massimini of the University of Milan have already tested the idea in severely brain-damaged, non-communicative patientsincluding vegetative-state patients, minimally conscious patients, and those with locked-in syndrome, who are fully conscious but unable to moveand found the technique proved its worth. In minimally conscious patients, the magnetically stimulated signals propagated fairly far and wide, occasionally reaching distant cortical areas, much like activations seen in locked-in but conscious patients. In patients in a persistent vegetative state, on the other hand, propagation was severely limiteda breakdown of connectivity similar to that observed in previous tests of anesthetized patients. Whats more, in three vegetative patients that later recovered consciousness, the test picked up signs of increased connectivity before clinical signs of improvement became evident. The results, published in Brain in January 2012, suggested that effective connectivity does correspond to the state of consciousness in patients with brain disorders, said Pearce, and that the combined TMS/EEG approach is an effective way to measure consciousness in brain-damaged patients who cannot communicate with the outside world. I think understanding consciousness itself is going to help us find successful [measurement] approaches that are universally applicable, said Pearce. Correction (April 18): Patrick Purdon is an instructor of anesthesia and bioengineer at Harvard Medical School and Massachusetts General Hospital, not an anesthesiologist or a neuroscientist at the Massachusetts Institute of Technology, as previously stated. The text has been changed to reflect this.The Scientist regrets the error.

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