47 Disability is a vital part of the ABCDE assessment process. It reveals both primary and secondary neurological problems and thus enables prompt therapeutic intervention which, in many cases, can be life-saving. Firstly, the patient’s level of consciousness (LOC) needs to be determined. The LOC is controlled by the reticular activating system (Chapter 46) and two distinct components of LOC are thought to exist: arousal, indicating how awake an individual is, and awareness which determines cognitive function and the extent to which the patient is able to recognise and respond to the general environment. Impaired consciousness may occur for a variety of reasons, including: primary injuries to the brain secondary to trauma or vascular accident; hypoxaemia; acidosis; infective disorders; status epilepticus; hypothermia; biochemical and metabolic disturbances; drug overdose; and poisoning. For some people rapid deterioration will occur requiring equally fast and accurate assessment, in the first instance the use of the AVPU scale1 (Table 47.1), is recommended. This will reveal whether the patient is fully alert, verbalises appropriately, responds to pain (Figure 47.1) or doesn’t respond to anything. Signs and symptoms of stroke (Chapter 48) should always be looked for, using the Face, Arm, Speech and Time (FAST) test (Figure 47.2). The Glasgow Coma Scale (GCS)(Table 47.2) is commonly used to monitor deficits if neurological impairment is established.2
Neurological assessment
Assessment of impaired consciousness
Glasgow Coma Scale
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