Acute Change in Level of Consciousness with Tremors and Weakness

Immediate Assessment and Stabilization

The American Heart Association recommends administering supplemental oxygen if saturation <94% or unknown, as hypoxemia exacerbates brain injury and worsens outcomes 3
The American College of Cardiology suggests using the FOUR score rather than Glasgow Coma Scale for assessing patients with acute change in level of consciousness, as it provides superior assessment for severely affected patients and evaluates brainstem reflexes critical for detecting deterioration 1, 4
Progression of motor posturing from decorticate to decerebrate posturing indicates rostral-caudal deterioration and impending herniation 2

The American Academy of Neurology recommends MRI brain with diffusion-weighted imaging if CT non-diagnostic and patient stable enough for transfer—superior for detecting acute ischemia, posterior fossa lesions, and encephalitis 5, 1
Standard EEG within 24 hours is recommended to detect non-convulsive status epilepticus—visual analysis has high specificity for detecting preserved consciousness 5, 1
Quantitative high-density EEG should be considered if standard EEG non-diagnostic and consciousness disorder persists beyond acute phase 5, 1

Focal weakness with altered consciousness should be evaluated using the NIH Stroke Scale to quantify deficits, as stroke is a potential cause until proven otherwise 6, 7, 3
The American Heart Association recommends activating stroke team if focal deficits present with symptom onset <24 hours 3
The Cincinnati Prehospital Stroke Scale (facial droop, arm drift, speech abnormalities) should be used to evaluate patients with suspected stroke—a single abnormality has 59% sensitivity, 89% specificity 3

For traumatic brain injury cases, SPECT scan at 1-2 months post-injury may assist in predicting 12-month recovery and degree of disability (Level B recommendation) 8, 5, 1
Functional MRI with active paradigms at 1-60 months post-injury may detect covert consciousness in patients without command-following at bedside 5, 1
Somatosensory evoked potentials (SEPs) may assist in predicting consciousness recovery at 24 months in anoxic brain injury cases 8, 5, 1

Rapid progression of motor posturing (decorticate to decerebrate within 20 minutes) indicates poor prognosis and warrants immediate neurosurgical consultation 2