West Haven Criteria
Grading of hepatic encephalopathy — prehospital reference
Grade 0
Minimal / subclinical
- No detectable personality or behavioural change
- No asterixis
- Only detectable on psychometric/neurophysiological testing
Not clinically apparent
Grade 1
Trivial
- Trivial lack of awareness
- Shortened attention span
- Mild disorientation for time (day, date)
- Euphoria or anxiety
- Impaired performance of addition/subtraction
- Sleep pattern reversal (day sleeping, night wakefulness)
Often missed — "a bit vague"
Grade 2
Moderate
- Lethargy or apathy
- Disorientation for time — more obvious
- Obvious personality change
- Inappropriate behaviour
- Dyspraxia (can't construct simple figures)
- Asterixis usually present
Poor retention / memory fits here or grade 1
Grade 3
Severe
- Somnolence to semi-stupor, but responsive to verbal stimuli
- Confusion, gross disorientation (time and place)
- Bizarre behaviour
- Asterixis usually cannot be tested — patient too drowsy/uncooperative
Reduced GCS likely
Grade 4
Coma
- Unresponsive to verbal or noxious stimuli
- Decorticate/decerebrate posturing may be present
- No asterixis testable
GCS ≤8 — airway risk
Prehospital application
Quick screen: orientation to person/place/time + short-term recall (register 3 items, recall after a few minutes) + look for asterixis (arms outstretched, wrists extended, watch for flap).
Trap: Grade 1 patients often present as pleasantly chatty and "a bit vague" — no agitation, no obvious flap, normal GCS. Easy to under-triage. Any new disorientation or memory impairment in a jaundiced or known-cirrhotic patient should be treated as decompensation until proven otherwise.
Handover value: a West Haven grade (even approximate) is more useful to receiving clinicians than "confused" alone — it tells them where on the trajectory the patient sits and how fast things might be moving.
Precipitants to consider/ask about: GI bleed (melaena, haematemesis, known varices), infection (esp. spontaneous bacterial peritonitis), constipation, electrolyte disturbance, new sedatives/opioids/benzodiazepines, alcohol, non-compliance with lactulose/rifaximin if known cirrhotic, dehydration, TIPS procedure history.
Reference
| Grade | Consciousness | Key feature |
|---|
| 0 | Normal | No detectable change |
| 1 | Normal | Mild inattention, time disorientation |
| 2 | Lethargic | Obvious disorientation, asterixis |
| 3 | Somnolent, rousable | Gross confusion |
| 4 | Coma | Unresponsive |