Altered Level of Consciousness Emergencies

Learn How EMTs & Paramedics Identify, Treat and Care for Patients with Altered Level of Consciousness Emergencies

An altered level of consciousness is the seventh most common emergency that EMS professionals respond to, accounting for almost 7% of all EMS calls.

(Click here for our list of the most common EMS Emergencies for EMTs and Paramedics).

An altered level of consciousness (ALOC) means that you are not as awake, alert, or able to understand as you normally. ALOC can be caused by a head injury, medicines, alcohol, drugs, dehydration, and even some diseases, such as diabetes.

Different levels of ALOC include:

• Confusion: you are easily distracted and may be slow to respond. You may not know who or where you are or the time of day or year.
• Delirium: you have severe confusion and disorientation and may have delusions (belief in things that are not real) or hallucinations (sensing things that are not real). The degree of confusion may get better or worse over time.
• Somnolent: you are sleeping unless someone or something wakes you up. You can usually talk and follow directions, but you may have trouble staying awake.
• Obtunded or lethargic: you are tired and less aware or less interested in your surroundings.
• Stupor: you are in a deep sleep unless something loud or painful wakes you up. You may not be able to talk or follow directions well, and you will fall back to sleep when left alone.
• Coma: you’re asleep, but you cannot be awakened at all.

Stupor and coma are rated according to how severe the symptoms are.

Altered Level of Consciousness Definition

What is Altered Level of Consciousness?

Level of consciousness is a measurement of a person’s responsiveness to stimuli from the environment. An altered level of consciousness is any measure of arousal or stimulation other than normal.  A mildly depressed level of alertness may be classified as lethargy, a state where a person may be aroused with little difficulty. People who are obtunded have a more depressed level of consciousness and cannot be fully aroused. Those who are not able to be aroused from a sleep-like state are said to be stuporous. Coma is the inability to make any purposeful response. Scales such as the Glasgow coma scale have been designed to measure the level of consciousness.

ALOC can result from various factors, including changes in the brain chemistry (e.g., exposure to poison or intoxicants), insufficient oxygen or blood flow in the brain, or excessive pressure on the brain. Prolonged unconsciousness is a sign of a medical emergency. A deficit in the level of consciousness could mean that the cerebral hemispheres or the reticular activating system have been injured. A decreased level of consciousness correlates to increased morbidity (sickness) and mortality (death). ALOC is a valuable measure of a patient’s medical and neurological condition. Some doctors consider level of consciousness to be one of the vital signs, along with body temperature, blood pressure, and heart rate.

An altered level of consciousness can take on many forms. In general, signs of ALOC include when a patient is not acting like their baseline, seems confused and disoriented, or is not acting normally. A patient can present with an impaired level of consciousness and may be lethargic, stuporous, or comatose. The patient may have been speaking to themselves or hallucinating. The patient may also seem hyper-alert, agitated, confused, or disoriented.

Levels of ALOC

Altered levels of consciousness can occur at different levels of intensity, as described in the table below. In general, any reduction in response to stimuli indicates an altered level of consciousness.

Level	Summary	Description
Metaconscious	Preternatural	People who can monitor and control their cognitive processes in addition to demonstrating a normal level of consciousness.
Conscious	Normal	People who can promptly state their name, location, date, or time are oriented to self, place, and time (also called “oriented 3X”).
Confused	Disoriented; impaired thinking and responses	People who do not respond quickly with information about their name, location, and time are considered “obtuse” or “confused.” A confused person may be bewildered, disoriented, and have difficulty following instructions.[9] The person may have slow thinking and possible memory time loss. This could be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs (prescription and nonprescription), and infection.
Delirious	Disoriented; restlessness, hallucinations, sometimes delusions	People who may be restless or agitated and exhibit a marked deficit in attention.
Somnolent	Sleepy	People who are excessively drowsy and respond to stimuli only with incoherent mumbles or disorganized movements.
Obtunded	Decreased alertness; slowed psychomotor responses	People who have decreased interest in their surroundings, slowed responses, and sleepiness.
Stuporous	Sleep-like state (not unconscious); little/no spontaneous activity	People with an even lower level of consciousness that only respond by grimacing or drawing away from painful stimuli.
Comatose	Cannot be aroused; no response to stimuli	People who make no response to stimuli, have no corneal or gag reflex, and may have no pupillary response to light.

Causes of ALOC

ALOC can be caused by the following conditions:

Type	Examples
Infectious	•  Pneumonia •  Urinary tract infection •  Meningitis or encephalitis •  Sepsis
Metabolic/toxic	•  Hypoglycemia •  Alcohol ingestion •  Electrolyte abnormalities •  Hepatic encephalopathy •  Thyroid disorders •  Alcohol or drug withdrawal
Neurologic	•  Stroke or transient ischemic attack •  Seizure or postictal state •  Subarachnoid hemorrhage •  Intracranial hemorrhage •  Central nervous system mass lesion •  Subdural hematoma
Cardiopulmonary	•  Congestive heart failure •  Myocardial infarction •  Pulmonary embolism •  Hypoxia or CO2 narcosis
Drug-related	•  Anticholinergic drugs •  Alcohol or drug withdrawal •  Sedatives-hypnotics •  Narcotic analgesics •  Polypharmacy

When to Call 911 for ALOC

According to the American College of Emergency Physicians, ALOC or changes in mental status are warning signs of a medical emergency, and you should call 911.

Call 911 if you are experiencing ALOC and are alone. Do not drive yourself to the hospital if you are having severe chest pain or severe bleeding or if your vision is impaired. Taking an ambulance is safer because paramedics can deliver life-saving care on route to the hospital.

If someone else shows signs of ALOC or altered mental status, call 911 immediately.

Note: If you are not sure whether the situation is truly an emergency, call 911, and let the dispatcher decide whether you need emergency help. Many 911 centers will be able to tell you what to do until help arrives.

How to Treat ALOC

All episodes of ALOC require careful observation, especially in the first 24 hours. ALOC patients will require hospitalization for monitoring, testing, and treatment.

When evaluating a patient for an altered mental state, it is essential to gather as much of the patient’s history as possible and to perform a complete head-to-toe physical exam. Since patients often are unable to provide their history because of their altered state, a record should be obtained from a family member or a medical facility to determine their baseline mental status. You should review the patient’s medication history in the electronic medical record (EMR) or call the pharmacy.

ALOC patients will be monitored continually and checked frequently for the following signs:

• Heart rate, blood pressure, and temperature
• Blood oxygen level
• Strength, range of motion, and ability to feel pain

ALOC testing may include:

• Blood tests to check for blood sugar, oxygen level, dehydration, infections, drugs, or alcohol
• Blood, urine, and other tests to monitor the function of various organs
• Neurologic examination to check strength, sensation, balance, reflexes, and memory
• Computed tomography (CT) scan to check for brain injury or diseases of the brain
• Magnetic resonance imaging (MRI) to check for brain injury or diseases of the brain
• X-rays of the chest to check for lung problems

Treatment for ALOC depends on its cause, symptoms, overall health of the patient, and any complications.  ALOC patients may expect:

• An IV catheter inserted into a vein in their hand or arm
• An oxygen tube placed under their nose or an oxygen mask placed over their face
• Prescription medicine to:
  • Treat or prevent an infection
  • Reduce swelling in and around the brain and spinal cord
  • Control blood sugar level

How can you help someone with ALOC?

Healthcare providers will need to know about the ALOC patient’s health history. If the patient is unable to provide this information, an informed caregiver should be on hand. Tell the healthcare team about any of the following conditions:

• Seizures or convulsions
• Bleeding from ears or nose
• Slurred speech
• Trouble with muscle movements, such as swallowing, moving arms and legs
• Dizziness
• Confusion
• Change in vision, such as double vision, blurred vision, or trouble seeing out of one or both eyes
• Restlessness
• Irritability
• Trouble staying awake or alert
• Vomiting
• Headache that will not go away after treatment
• Tiredness
• Loss of balance or coordination
• Loss of memory
• Unusual behavior

How Do EMTs & Paramedics Treat ALOC

For all clinical emergencies, the first step is a rapid and systematic assessment of the patient. For this assessment, most EMS providers will use the ABCDE approach.

The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is applicable in all clinical emergencies for immediate assessment and treatment. It can be used in the street with or without any equipment. It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals, or intensive care units.

Treatment Guidelines & Resources for Medical First Responders

Treatment guidelines for altered level of consciousness can be found on page 66 of the National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO). NASEMSO maintains these guidelines to facilitate state and local EMS system clinical guidelines, protocols, and operating procedures. These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.

The guidelines include the following treatment and interventions:

Look for treatable causes of altered mental status:

1. Airway – Make sure airway remains patent; reposition patient as needed
2. Breathing – Look for respiratory depression; check SPO2, ETCO2, and CO detector readings
3. Circulation – Look for signs of shock
4. Glasgow Coma Score and/or AVPU
5. Pupils
6. Neck rigidity or pain with range of motion
7. Stroke tool
8. Blood glucose level
9. EKG – Arrhythmia limiting perfusion
10. Breath odor – Possible unusual odors include alcohol, acidosis, ammonia
11. Chest/Abdominal – Intra-thoracic hardware, assist devices, abdominal pain or distention
12. Extremities/skin – Track marks, hydration, edema, dialysis shunt, temperature to touch (or if able, use a thermometer)
13. Environment – Survey for pills, paraphernalia, ambient temperature

EMS Protocol for ALOC Emergencies

Protocols for pre-hospital treatment of altered level of consciousness vary by EMS provider and can also depend on the patient’s symptoms or medical history.

Note: Request Advanced Life Support if available. Do NOT delay transport to the appropriate hospital.

Note: This protocol is for patients who are NOT alert but responsive to verbal stimuli, responding to painful stimuli, or unresponsive.

1. Assess the situation for potential or actual danger. If the scene/situation is not safe, retreat to a safe location, create a safe zone, and obtain additional assistance from a police agency. Emotionally disturbed patients must be presumed to have an underlying medical or traumatic condition causing the altered mental status.
   • All suicidal or violent threats or gestures must be taken seriously. These patients should be in police custody if they pose a danger to themselves or others. If the patient poses a danger to themselves and/or others, call the police for assistance.
2. Perform primary assessment. Assure that the patient’s airway is open and that breathing and circulation are adequate. Suction as necessary.
3. Administer high concentration oxygen. In children, humidified oxygen is preferred.
4. Obtain and record the patient’s vital signs, including determining the patient’s level of consciousness. Assess and monitor the Glasgow Coma Scale.
   • If the patient is unresponsive or responds only to painful stimuli, prepare for transport while continuing care.
   • If the patient has a known history of diabetes controlled by medication, is conscious, can drink without assistance, provide an oral glucose solution, fruit juice, or non-diet soda by mouth, then transport, keeping the patient warm. If regionally approved to obtain blood glucose levels utilizing a glucometer, follow your regionally approved protocol.
   • If the patient has a suspected opioid overdose:
     • If the patient does not respond to verbal stimuli, but either responds to painful stimuli or is unresponsive; and
     • Respirations less than 10/minute and signs of respiratory failure or respiratory arrest, refer to appropriate respiratory protocol.
     • If regionally approved and available, obtain the patient’s blood glucose (BG) level.
       • If BG is less than 60, in adult and pediatric patients, follow IV above.
       • If BG is more than 60 in adult and pediatric patients, proceed to the next step.
     • Administer naloxone (Narcan^®) via a mucosal atomizer device (MAD).
       • Relative contraindications:
         • Cardiopulmonary arrest
         • Seizure activity during this incident
         • Evidence of nasal trauma, nasal obstruction and/or epistaxis
       • Insert MAD into patient’s left nostril and for:
         • ADULT: inject 1mg/1ml
         • PEDIATRIC: inject 0.5mg/05ml
       • Insert MAD into patient’s right nostril and for:
         • ADULT: inject 1mg/1ml
         • PEDIATRIC: inject 0.5mg/05ml
       • Initiate transport. After 5 minutes, if the patient’s respiratory rate is not greater than 10 breaths/minute, administer a second dose of naloxone following the same procedure as above and contact medical control.
       • If an underlying medical or traumatic condition causing an altered mental status is not apparent, the patient is fully conscious, alert, and able to communicate; and an emotional disturbance is suspected, proceed to the Behavioral Emergencies protocol.
       • Transport to the closest appropriate facility while re-evaluating vital signs every 5 minutes and reassess as necessary.
       • Record all patient care information, including the patient’s medical history and all treatment provided, on a Prehospital Care Report (PCR).

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