How to Check for Consciousness

by

The Definitive Guide to Assessing Consciousness: A Comprehensive Health Perspective

Understanding how to check for consciousness is a critical skill, not just for medical professionals, but for anyone who might encounter an emergency situation. From a simple faint to a severe head injury, a person’s level of consciousness can rapidly change, dictating the urgency and type of intervention required. This in-depth guide will equip you with the knowledge and practical steps to accurately assess consciousness, focusing on clear, actionable methods that are both human-like in their approach and medically sound. We’ll explore various scenarios, delve into the nuances of different levels of awareness, and provide concrete examples to ensure you’re prepared for any eventuality.

Why is Assessing Consciousness So Crucial?

The ability to determine someone’s level of consciousness is paramount in emergency response and ongoing patient care for several compelling reasons:

  • Triage and Prioritization: In a mass casualty incident or even a single accident, quickly assessing consciousness helps first responders prioritize who needs immediate attention. An unconscious person with a compromised airway, for instance, requires more urgent intervention than someone who is awake and alert but has a minor injury.

  • Guiding Immediate Actions: A person’s conscious state dictates the initial steps you take. If someone is unconscious and not breathing, CPR is necessary. If they are unconscious but breathing, placing them in the recovery position is crucial to prevent aspiration.

  • Monitoring Deterioration or Improvement: In a hospital setting or during prolonged pre-hospital care, serial assessments of consciousness allow medical professionals to track a patient’s neurological status. A decline in consciousness can signal a worsening condition, such as increasing intracranial pressure or internal bleeding, prompting immediate medical intervention. Conversely, improvement indicates the effectiveness of treatment.

  • Identifying Underlying Causes: Changes in consciousness can be symptoms of a wide range of medical emergencies, including stroke, diabetic ketoacidosis, overdose, seizure, or severe infection. A thorough assessment helps healthcare providers narrow down potential causes and initiate appropriate diagnostic tests.

  • Ensuring Safety: For both the unconscious individual and those assisting them, understanding consciousness levels helps ensure safety. For example, an agitated, disoriented patient might pose a risk to themselves or others if not managed appropriately.

The Spectrum of Consciousness: More Than Just “Awake” or “Asleep”

Consciousness isn’t a simple on/off switch; it exists on a continuum. Understanding this spectrum is fundamental to accurate assessment.

  • Alert and Oriented (A&Ox4): This is the highest level of consciousness. The person is fully awake, aware of their surroundings, and able to interact meaningfully. They know who they are, where they are, what time it is, and why they are there (person, place, time, situation).

  • Lethargic: The person is drowsy and can be aroused with mild stimulation (e.g., calling their name or light touch), but they quickly drift back to sleep if not continuously stimulated. Their responses might be slow or delayed.

  • Obtunded: More difficult to arouse than a lethargic person. They require more vigorous stimulation, such as shaking or loud verbal commands. Once aroused, they may be confused or slow to respond, and their interactions are minimal. They may only respond to pain.

  • Stuporous: The person is generally unresponsive and requires continuous, vigorous, and painful stimulation (e.g., sternal rub, nailbed pressure) to elicit any response. Their responses are typically minimal, such as groaning, moaning, or withdrawing from the painful stimulus. They are not spontaneously awake.

  • Comatose: The deepest state of unconsciousness. The person is completely unresponsive to all forms of stimulation, including painful stimuli. They may exhibit no purposeful movement or only abnormal posturing (decorticate or decerebrate rigidity). This is a medical emergency.

Initial Assessment: The “Look, Listen, Feel” Approach and AVPU Scale

When you first encounter someone whose consciousness is in question, a rapid, systematic approach is vital. Before any hands-on assessment, ensure the scene is safe for both you and the individual.

Step 1: Environmental Scan and Verbal Stimulation

  • Safety First: Before approaching, quickly scan the environment for any hazards (e.g., traffic, falling debris, downed power lines, fumes). Your safety is paramount.

  • Verbal Call Out: From a safe distance, try to elicit a response by speaking loudly and clearly. Start with their name if you know it. If not, try “Hello? Can you hear me?” or “Are you okay?” Observe for any verbal response, eye opening, or body movement.

Step 2: Gentle Physical Stimulation

If there’s no response to verbal commands, proceed to gentle physical stimulation.

  • Light Touch: Gently tap their shoulder. If they’re a child, a gentle tap on the foot might be more appropriate.

  • Shake Gently: If tapping doesn’t work, gently shake their shoulder (for adults) or foot (for infants). Avoid vigorous shaking, especially if there’s a suspected neck or spinal injury.

Introducing the AVPU Scale: A Rapid Snapshot

The AVPU scale is a quick, simple method for assessing a person’s level of consciousness in emergency situations. It’s often the first step paramedics and first responders use.

  • A – Alert: The person is fully awake, eyes open, and spontaneously interacts with their environment. They may respond appropriately to questions.
    • Example: You approach someone who has fallen. Their eyes are open, they look at you, and when you ask “Are you okay?”, they say “Yes, I tripped.”
  • V – Responds to Voice: The person is not spontaneously alert, but they respond when you speak to them. This response could be opening their eyes, making a sound, or moving a limb.
    • Example: You call out “Hello, can you hear me?” The person slowly opens their eyes and groans, but doesn’t speak.
  • P – Responds to Pain: The person does not respond to voice, but responds to a painful stimulus. This response might be a moan, a grunt, withdrawing a limb, or grimacing.
    • Example: You perform a sternal rub (see “Painful Stimuli” section below), and the person groans and tries to push your hand away.
  • U – Unresponsive: The person does not respond to voice or painful stimuli.
    • Example: You try calling their name and applying a sternal rub, but there is no reaction whatsoever.

Action Point: Based on the AVPU assessment, if the person is anything less than “Alert,” you should consider activating emergency medical services (EMS) immediately (call 911 or your local emergency number).

Deeper Dive: The Glasgow Coma Scale (GCS)

While AVPU provides a rapid overview, the Glasgow Coma Scale (GCS) offers a more detailed and objective assessment of consciousness. It’s widely used in hospitals, pre-hospital settings, and research to track changes in neurological status over time. The GCS assesses three key areas:

  1. Eye Opening (E)

  2. Verbal Response (V)

  3. Motor Response (M)

Each area is assigned a score, and these scores are summed to give a total GCS score ranging from 3 (deep coma) to 15 (fully conscious).

1. Eye Opening (E) – Score 1-4

This component assesses the person’s ability to open their eyes, indicating brainstem function.

  • 4 – Spontaneous: Eyes open without any stimulation. The person is naturally looking around or fixating.
    • Example: You walk into a room, and the person is already awake with their eyes open, looking at you or their surroundings.
  • 3 – To Voice: Eyes open only when you speak to them (e.g., calling their name, “Open your eyes!”). The voice can be normal or loud.
    • Example: You say “Hello?” and their eyes slowly open.
  • 2 – To Pain: Eyes open only in response to a painful stimulus.
    • Example: You apply a sternal rub, and their eyes open in response to the discomfort.
  • 1 – No Response: No eye opening despite any stimulation.
    • Example: Their eyes remain closed even after painful stimuli.

2. Verbal Response (V) – Score 1-5

This component assesses the person’s ability to produce understandable speech, reflecting higher cortical function.

  • 5 – Oriented: The person is able to answer questions about their name, location, date/time, and the reason for being there accurately. They are coherent and conversing appropriately.
    • Example: “What’s your name?” “John.” “Where are you?” “In the hospital.” “What day is it?” “Thursday.”
  • 4 – Confused: The person responds to questions, but their answers are incorrect, disoriented, or inappropriate to the context. They might be speaking in sentences but are confused about facts.
    • Example: “What day is it?” “It’s Christmas.” “Where are you?” “At the beach.”
  • 3 – Inappropriate Words: The person speaks, but the words are random, disconnected, or make no sense in context. They might utter expletives or unrelated phrases. There is no conversational exchange.
    • Example: You ask “How are you feeling?” and they say “Banana table purple.”
  • 2 – Incomprehensible Sounds: The person makes only sounds like moaning, groaning, or grunting, without forming any recognizable words.
    • Example: You ask a question, and they just emit a guttural moan.
  • 1 – No Response: No verbal sounds whatsoever, even with stimulation.
    • Example: Complete silence despite attempts to elicit a verbal response.

3. Motor Response (M) – Score 1-6

This component assesses the person’s best motor response to commands or painful stimuli, indicating the integrity of motor pathways. This is often the most reliable component in severely impaired patients.

  • 6 – Obeys Commands: The person is able to follow simple instructions consistently (e.g., “Squeeze my hand,” “Lift your arm,” “Show me two fingers”).
    • Example: You say “Can you lift your right arm?” and they lift it.
  • 5 – Localizes to Pain: The person attempts to remove or push away the painful stimulus with a purposeful movement of the limb. They cross the midline of the body to reach the stimulus.
    • Example: You apply a painful stimulus to their left arm, and they purposefully reach across with their right hand to push your hand away.
  • 4 – Withdraws from Pain (Normal Flexion): The person flexes their limb away from the painful stimulus, but the movement is not purposeful (i.e., they don’t try to localize or remove the stimulus). This is a general withdrawal reflex.
    • Example: You apply a painful stimulus to their arm, and they quickly pull the arm back.
  • 3 – Abnormal Flexion (Decorticate Posturing): The person exhibits an abnormal posture in response to pain. Arms are flexed at the elbow and wrist, held tightly to the chest, and legs are extended. This indicates damage to pathways above the red nucleus.
    • Example: When a painful stimulus is applied, their arms curl inward towards their core, and their legs straighten.
  • 2 – Extension (Decerebrate Posturing): The person exhibits an abnormal posture where the arms and legs are extended, wrists are pronated, and fingers are flexed. The head may be arched back. This indicates more severe brainstem damage.
    • Example: When a painful stimulus is applied, their arms and legs stiffen and extend outwards, with wrists turning inwards.
  • 1 – No Response: No motor movement whatsoever, even with painful stimuli.
    • Example: The body remains flaccid and still despite any stimulation.

Calculating and Interpreting the GCS Score

Add the scores from Eye Opening (E), Verbal Response (V), and Motor Response (M) to get the total GCS score.

  • GCS 13-15: Mild brain injury or fully conscious.

  • GCS 9-12: Moderate brain injury.

  • GCS 3-8: Severe brain injury or comatose. A GCS of 8 or less typically indicates a need for airway protection (intubation).

  • GCS 3: The lowest possible score, indicating a deep coma or brain death.

Action Point: When assessing GCS, always record the individual scores (e.g., GCS E4 V5 M6 = 15) as well as the total. This provides more specific information about which areas of brain function are affected.

Administering Painful Stimuli Safely and Ethically

When a person doesn’t respond to verbal commands, painful stimuli are used to assess the “P” in AVPU and the “E” and “M” components of GCS. It’s crucial to apply these stimuli correctly, ethically, and without causing permanent harm. The goal is to elicit a response, not inflict injury.

Recommended Painful Stimuli:

  • Sternal Rub: This is a commonly used and effective method.
    • How to Perform: Make a fist and place your knuckles firmly on the person’s sternum (breastbone). Apply firm, rotating pressure for up to 5-10 seconds.

    • Why it Works: The sternum is covered by a thin layer of skin and subcutaneous tissue, making the pressure directly stimulate bone and nerve endings.

    • Caution: Do not apply excessive force that could cause bruising or injury to the sternum.

  • Trapezius Pinch: A good alternative to the sternal rub.

    • How to Perform: Pinch and twist a significant portion of the trapezius muscle (the muscle at the base of the neck, between the shoulder and neck) between your thumb and forefinger for up to 5-10 seconds.

    • Why it Works: This large muscle is sensitive to pinching.

    • Caution: Ensure you are pinching a good amount of muscle, not just skin, to be effective.

  • Supraorbital Pressure (Less Common, Use with Caution): Applying pressure above the eye.

    • How to Perform: Press firmly with your thumb upwards into the notch just under the eyebrow, on the bony ridge.

    • Why it Works: This area has a nerve that is sensitive to pressure.

    • Caution: Avoid pressing directly on the eyeball. Not recommended for individuals with facial trauma or eye injuries.

  • Nail Bed Pressure: Can be used, but less common for initial assessment as it can be less effective and potentially damaging if done incorrectly.

    • How to Perform: Apply firm pressure with a pen or your thumb to the nail bed (base of the fingernail) for up to 5-10 seconds.

    • Caution: Avoid causing injury to the nail bed.

What to Observe During Painful Stimuli:

  • Eye Opening: Do their eyes open in response?

  • Verbal Response: Do they moan, groan, or make any sounds?

  • Motor Response: Do they withdraw from the stimulus, localize it, or exhibit abnormal posturing?

Action Point: Always start with the least invasive methods and escalate if no response is observed. If the person responds to a painful stimulus, immediately cease applying the stimulus. You’ve obtained the information needed.

Recognizing and Responding to Different States of Consciousness

Beyond simply scoring, understanding the implications of different states of consciousness is crucial for effective response.

The Faint (Syncope)

  • Characteristics: Brief, sudden loss of consciousness due to temporary reduction in blood flow to the brain. Often preceded by dizziness, lightheadedness, nausea, or a “blacking out” sensation. Recovery is usually rapid and complete.

  • Action: If someone faints, help them lie down with their legs elevated 12 inches above their heart to improve blood flow to the brain. Loosen any tight clothing around their neck. If they don’t recover within a minute or two, or if they hit their head, seek medical attention.

  • Example: A person standing in a hot, crowded room suddenly slumps to the floor. Their eyes are closed, but they’re breathing. You quickly lie them down, and within 30 seconds, their eyes flutter open, and they say they feel dizzy.

Seizures

  • Characteristics: Episodes of abnormal brain activity that can cause a range of symptoms, including loss of consciousness, uncontrolled muscle movements (convulsions), confusion, and staring spells. Consciousness may be impaired during and after the seizure.

  • Action: Protect the person from injury during the seizure (e.g., move objects away, place something soft under their head). Do NOT restrain them or put anything in their mouth. Time the seizure. After the seizure, the person may be confused, drowsy, or disoriented (post-ictal state). Monitor their breathing and consciousness.

  • Example: A person suddenly falls to the ground, their body stiffens, and then they begin to jerk uncontrollably. Their eyes are rolled back. After a minute, the jerking stops, and they appear unresponsive and then very drowsy, slowly regaining some awareness but are confused about what happened.

Stroke

  • Characteristics: A medical emergency where blood flow to part of the brain is interrupted. Can cause sudden weakness or numbness on one side of the body, facial drooping, speech difficulties (slurred or confused), and altered consciousness.

  • Action: If you suspect a stroke (think FAST: Face drooping, Arm weakness, Speech difficulty, Time to call 911), call emergency services immediately. Do not give them anything to eat or drink. Monitor their consciousness and breathing.

  • Example: A person at dinner suddenly slumps in their chair. Their right arm is limp, and when you try to talk to them, their speech is garbled, and they seem confused and drowsy.

Head Injury

  • Characteristics: Trauma to the head can range from a mild concussion to a severe brain injury. Symptoms can include headache, dizziness, nausea, confusion, memory loss, and altered consciousness (from brief loss to prolonged coma).

  • Action: Assume a neck or spinal injury until proven otherwise. Do not move the person unnecessarily. Keep them still and supported. Monitor their level of consciousness closely, looking for any deterioration (e.g., becoming more drowsy, difficult to rouse, new weakness). Seek immediate medical attention for any loss of consciousness, persistent confusion, or worsening symptoms after a head injury.

  • Example: A person falls off a ladder and hits their head. They were initially unconscious for a few seconds, then woke up but are very confused and keep asking the same questions.

Hypoglycemia (Low Blood Sugar)

  • Characteristics: In people with diabetes, blood sugar levels can drop too low, leading to confusion, dizziness, sweating, tremors, and in severe cases, loss of consciousness or seizures.

  • Action: If the person is conscious and able to swallow, give them something sugary (e.g., fruit juice, regular soda, glucose tablets). If they are unconscious or unable to swallow, do NOT give them anything by mouth; call emergency services immediately.

  • Example: A known diabetic person suddenly becomes agitated and disoriented, then slumps down, becoming unresponsive. Their skin is clammy and cool.

Overdose (Drug or Alcohol)

  • Characteristics: Can depress the central nervous system, leading to drowsiness, stupor, coma, slowed breathing, and reduced reflexes.

  • Action: Call emergency services immediately. Be prepared to provide information about what substances might have been consumed if known. Monitor their breathing and place them in the recovery position if they are unconscious but breathing, to prevent aspiration.

  • Example: You find someone unresponsive with shallow breathing, empty pill bottles nearby, and they respond only to painful stimuli with a groan.

Ongoing Monitoring: Vital Signs and Reassessment

Assessing consciousness is not a one-time event, especially in an emergency or medical setting. It’s a dynamic process that requires continuous monitoring.

Vital Signs Link to Consciousness

Changes in vital signs (pulse, respiration, blood pressure, temperature) often correlate with changes in consciousness.

  • Pulse: A very slow (bradycardia) or very fast (tachycardia) pulse can indicate various underlying issues affecting the brain and consciousness.

  • Respiration: Slow, shallow, or irregular breathing can signal a depressed central nervous system, often seen in overdose or severe brain injury. Rapid, deep breathing can be a sign of metabolic acidosis.

  • Blood Pressure: Extremely low or high blood pressure can impact brain perfusion and consciousness.

  • Temperature: Both very low (hypothermia) and very high (hyperthermia) body temperatures can profoundly affect brain function and lead to altered consciousness.

The Importance of Serial Assessments

  • Trend Analysis: Repeated GCS or AVPU assessments every 5-15 minutes (depending on the situation and stability) allow healthcare providers to identify trends. Is the person getting better, worse, or staying the same?

  • Early Intervention: A subtle but consistent decline in GCS score (even by one point) can be an early warning sign of worsening neurological status, prompting timely medical intervention.

  • Documentation: Meticulous documentation of all assessments, including time, score, and specific observations, is critical for continuity of care and legal purposes.

Action Point: If you are monitoring someone who has an altered level of consciousness, frequently reassess their state. Any significant change warrants immediate notification of medical professionals.

Red Flags: When to Seek Immediate Medical Help

While this guide empowers you with assessment skills, it’s equally important to know when to call for professional help without delay. Always activate emergency medical services (EMS) if you observe any of the following:

  • Any Loss of Consciousness, however brief, after a head injury.

  • Sudden, unexplained loss of consciousness.

  • Difficulty rousing the person (anything less than “Alert” on AVPU).

  • Inability to respond to voice or pain.

  • Seizures (especially if it’s their first seizure, lasts longer than 5 minutes, or they have repeated seizures).

  • Confusion or disorientation that is new or worsening.

  • Slurred speech or difficulty speaking.

  • Weakness or numbness on one side of the body.

  • Unequal pupil sizes or pupils that don’t react normally to light.

  • Persistent vomiting or severe headache after a head injury.

  • Difficulty breathing or abnormal breathing patterns.

  • Signs of significant trauma (e.g., severe bleeding, suspected fractures).

  • If you suspect overdose or poisoning.

  • If the person has a known medical condition (e.g., diabetes, heart condition) and suddenly experiences altered consciousness.

  • Any time you are unsure or concerned. It’s always better to err on the side of caution.

Practical Considerations and Nuances

Alcohol and Drug Intoxication

While intoxication can mimic altered consciousness, it’s crucial never to assume that drugs or alcohol are the sole cause of unresponsiveness. A person who is intoxicated could also have a head injury, stroke, or other medical emergency. Always assess them as if there were no substances involved, and err on the side of caution by seeking medical attention if their consciousness is significantly impaired.

Language Barriers and Communication Difficulties

When assessing verbal response, be mindful of language barriers. If possible, find an interpreter. For individuals with pre-existing communication difficulties (e.g., stroke survivors with aphasia, hearing impaired), rely more heavily on eye opening and motor responses, and adapt your verbal commands (e.g., using gestures, writing).

Children and Infants

Assessing consciousness in children and infants requires specific considerations:

  • AVPU is still applicable.

  • GCS Adaptation: There are modified GCS scales for infants and young children, but the principles remain similar.

  • Verbal Response (Children): Observe for babbling, crying, or age-appropriate words.

  • Motor Response (Infants): Observe for spontaneous movement, withdrawal from pain, or abnormal posturing.

  • Painful Stimuli (Infants): Gentle pressure on the sole of the foot or the nail bed can be used.

The Importance of a Calm Demeanor

In an emergency, maintaining a calm and confident demeanor is essential. This not only helps you think clearly but also reassures the affected person (if they are conscious) and any bystanders, allowing for a more effective assessment and response.

Conclusion

The ability to accurately check for consciousness is a life-saving skill that transcends professional boundaries. From the rapid AVPU scale to the more detailed Glasgow Coma Scale, understanding these assessment tools provides a structured approach to evaluating a person’s neurological status. Remember, consciousness exists on a spectrum, and changes in awareness can be the earliest and most critical indicators of an underlying medical emergency.

By following the systematic steps outlined in this guide – observing, stimulating, and methodically assessing eye opening, verbal response, and motor response – you can gain vital information that guides immediate actions and informs medical professionals. Always prioritize safety, act swiftly, and do not hesitate to call for professional medical help when in doubt. Your ability to assess consciousness can make all the difference in an emergency, offering critical insights that pave the way for timely and effective care.