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Altered Level of Consciousness

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

Overview

Altered level of consciousness (ALOC) is a common EMS presentation with a wide differential diagnosis spanning metabolic, neurologic, toxicologic, traumatic, cardiovascular, and environmental causes. It is not a diagnosis — it is a finding requiring systematic investigation to identify and treat reversible causes. Most causes can be found through methodical assessment: check the glucose, airway, oxygen, and vital signs before anything else.

Key Points

  • Always check blood glucose in any patient with ALOC — hypoglycemia is common, treatable, and rapidly reversible
  • Do not assume intoxication — many medical conditions mimic intoxication
  • AVPU scale: Alert, Verbal, Pain, Unresponsive — use to quantify and trend LOC
  • GCS (Glasgow Coma Scale) — used in trauma with TBI; Eyes (1–4) + Verbal (1–5) + Motor (1–6); score ≤8 = severe TBI, typically requires airway management
  • Unresponsive patients cannot protect their airway — position laterally, be prepared to suction
  • The underlying cause drives definitive treatment — EMT-B focuses on life-threatening causes and transport

Common Causes (AEIOU TIPS mnemonic or similar)

  • A — Alcohol/Acidosis
  • E — Epilepsy/seizure
  • I — Insulin/hypoglycemia
  • O — Overdose/opioids
  • U — Uremia (renal failure)
  • T — Trauma/head injury
  • I — Infection (CNS, sepsis)
  • P — Psychiatric/psychogenic
  • S — Stroke/syncope

NM protocol list: - Diabetic emergency, overdose, CVA/TIA, AMI, head trauma, dehydration, syncope, hypo/hyperthermia, shock or hypoperfusion, CNS infection

Assessment Relevance

Primary assessment (primary-assessment): - Airway: impaired LOC = impaired airway reflexes; suction, position, OPA/NPA - Breathing: rate, depth, quality; SpO2 - Circulation: HR, BP, skin (color, temperature, moisture) - AVPU scale — repeat at each reassessment to trend

History (history-taking): - SAMPLE: Prior medical conditions, medications (especially insulin, anticoagulants, seizure meds, cardiac meds), allergies, last meal, events preceding onset - Bystander/family input essential — patient may be unable to provide history - Onset: sudden (stroke, cardiac, hypoglycemia) vs. gradual (infection, DKA, hypothermia)

Physical exam (secondary-assessment): - Glucometry — mandatory first action after ABCs - Pupils: equal and reactive vs. unequal (herniation, drugs), pinpoint (opioids), blown (herniation) - Breath odor: acetone (DKA), alcohol, urine (renal failure) - Skin: pale/cool/moist (hypoglycemia, shock), hot/dry (hyperthermia, anticholinergic), jaundice (liver) - Focal neurologic deficits: stroke, TBI - Evidence of trauma (head wound, Battle's sign, raccoon eyes)

Procedures

  1. Scene size-up (scene-size-up): safety, MOI vs. NOI, need for additional resources; if trauma possible, c-spine consideration
  2. Primary assessment (primary-assessment): airway management is first priority — suction, position, OPA/NPA if no gag reflex
  3. Glucometry: if <60 mg/dL with AMS → treat per diabetic-emergencies
  4. If narcotic overdose suspected → naloxone per overdose-poisoning guideline
  5. Manage hypoxia with supplemental O2 per oxygen-administration
  6. If shock suspected → treat per bleeding-control-shock
  7. Transport without delay to appropriate facility
  8. Request ALS intercept (IV dextrose for unconscious hypoglycemia is ALS scope)
  9. Reassess every 5 minutes (reassessment): trend LOC, vital signs, treat identified causes

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B scope: - Primary assessment: airway, breathing, circulation — if occult trauma possible, consider spinal immobilization - Cardiac monitoring and 12-lead EKG if possible - Consider possible causes: diabetic emergency, overdose, CVA/TIA, AMI, head trauma, dehydration, syncope, hypo/hyperthermia, shock/hypoperfusion, CNS infection - Perform glucometry: - If BGL <60 mg/dL and/or associated signs of hypoglycemia → follow Diabetic Emergencies Guideline - If narcotic overdose suspected → follow Overdose/Poisoning Guidelines - Transport without delay to appropriate medical facility - If no ILS/ALS capability → radio for intercept - If signs of shock → follow Shock Guidelines - Active cooling or warming if indicated (hyperthermia, hypothermia) - If cardiac cause suspected → follow specific Cardiac Emergency Guidelines

ALS scope (IV access, IV dextrose, naloxone IV) — EMT-B should initiate ALS intercept early for unconscious patients

Post-ROSC: Check BGL after cardiac arrest — if <60 mg/dL treat per diabetic emergencies; if hyperglycemic, notify hospital

Note on naloxone: After naloxone, patient may rapidly awaken, become combative, and experience vomiting — consider this before inserting advanced airway device

NREMT Relevance

  • AVPU and GCS scale — know components and scoring
  • Always check BGL in ALOC
  • Medical causes mimic intoxication — never assume alcohol
  • Airway management priority: lateral position, suction, OPA/NPA for unconscious with no gag reflex
  • AEIOU TIPS mnemonic for ALOC causes
  • GCS ≤8 = severe TBI = needs airway management

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — Altered Level of Consciousness protocol (p. 35)