D R . S O N D I P O N M A L A K E R

M O , M U - 2

TA N G A I L M E D I C A L C O L L E G E H O S P I TA L .

Rational Prescription and

Emergency management of Unconscious Patient

RATIONAL PRESCRIPTION

Rational prescription…

Rational prescription means patient will receive the appropriate medicine according to the disease, in proper dose in proper formulation for an adequate period of time at the lowest cost to them & their community.

Steps of rational prescribing:

Make a diagnosis.Consider factors influencing patient’s response to therapy.Establish the therapeutic goal.Choose the therapeutic approach.Choose the drug & its formulation.Choose the dose, root, frequency .Choose the duration of the therapy.

Write an unambiguous prescription.Inform the patient about the treatment & its likely effects.Monitor the treatment effects both harmful & beneficial.Review or alter the prescription.

Rational prescribing includes…

Sometimes not prescribing any drug at all.. Good prescribing is not simply matching the disease and

the drug….Individualize the therapy….

Elements of prescription:

Name of the prescriberProfessional degreeAddressDate of prescriptionName of the patientAddress of the patientDrug name

Strength of the drugQuantity of the drug Route & method to be administrationAdvisePrescriber’s signatureLicense no. or registration no.

Rational prescribing requires:

Diagnostic skills.Knowledge of medicines.Detailed knowledge of the pathophysiology of the disease

of the patient. Clinical pharmacology of the drugs you are intended to

use. Evidence based practice.Individualization of risk-benefit ratio.Communication skills.

Common prescribing errors: Omission of needed information Poor prescription writing Inappropriate drug prescription

What contribute to irrational prescribing

Prescribers:Inadequate examination of the patient.Inadequate communication between patient & doctor.Lack of documented medical history.In adequate laboratory resources.Work overload of doctors.Prescribing incentives from Pharmaceutical companies.

Health care system:Lack of measurement of quality of prescription.Lack of evidence based clinical guidelines and

prescription policies.Inadequate training of undergraduates regarding

prescribing.Inadequate drug supply and health care personals.Unethical promotion of pharmaceutical products.

Types of irrational Drug use:Under prescribingOver prescribingIncorrect prescribing.Multiple prescribing

Consequences of Irrational prescribing

Low chances of benefit.Polypharmacy.Irrational use of antibiotics.Risk of ADR and drug-drug interactions.Waste of resourcesInappropriate treatment

Impact of Irrational Prescribing

a. Delay in cure

b. More Adverse Effects

c. Prolonged Hospitalization

d. Emergence of antimicrobial resistance

e. Loss of patient’s confidence in the doctor

f. Economical burden for the patient & the community

g. Lowering of health standards

Polypharmacy

Concomitant use of multiple drugs.Mainly seen in elderly patients.Polypharmacy can be-

Appropriate Inappropriate- most of the time.

Potential risk of polypharmacy:Increased risk of ADR and Drug resistance.Poor adherence to drug.Waste of money.

Managing polypharmacy:Non pharmacological approach.Avoid prescribing for minor, non specific or self limiting

conditions.Regular medication review.Simplify the treatment.Talk with patients about their personal choice.

Irrational use of Antibiotics

OveruseUnderuseInappropriate usePromotion by drug companiesLack of antibiotic policies, guidelines and regulations to

control inappropriate antibiotic use.

How to promote rational use of antibiotic:Educating the prescribers about the rational use of

antibiotics.Encouraging restrictions in prescribing antibiotics to

selected antibiotics.Promote review of antibiotic treatment during course of

illness.Audits and feedback.Improved diagnostic services.

Developing antibiotic policies and treatment guidelines.Regulation on quality and drug promotion. Surveillance of resistance pattern.Using local surveillance data in clinical management and

to update treatment guidelines.

RATIONALIZATION OF PRESCRIPTION PRACTISES

Most of the illness responds to simple, inexpensive drugs.Physician should avoid:

use of expensive drugs. use of drugs in nonspecific condition

(e.g. use of vitamins) use of not required forms

(e.g. injections in place of capsules , syrup in place of tablets)

WHO model for rational prescribing

P- drug concept

P drugs (Personal drugs) are the drugs, you have chosen to prescribe regularly , with whom you have become familiar.

they are your drugs of choice for given indications.Choosing and using only 50-60 drugs only among 1000s.

Selecting a P- drug

Step -1: Define the diagnosisStep -2: Specify the therapeutic objectiveStep- 3: Make an inventory of effective groups of drugsStep-4: Choose an effective group according to criteriaStep-5: Choose P- drug

ADVANTAGES OF P- DRUG

More convenientMore confidenceCan be able to master easilyDrug effects are predictableLess chance of unexpected adverse effects and drug

interactionsLess complication

ADVANTAGES OF P- DRUG

Possibility of adopting rational drug useLess burden on the physicianHealth care delivery is easyLess health care costs

EMERGENCY MANAGEMENT OF UNCONCIOUS PATIENT

In hospital emergency, the clinical analysis of unresponsive unconscious patient is always an urgency.

Physicians must therefore be prepared to implement a rapid, systematic approach for prompt therapeutic action.

NEURAL BASIS OF CONSCIOUSNESS

Maintenance of consciousness depends on interaction between ascending reticular activating system (ARAS) & cerebral hemispheres.

ARAS extends from the lower border of the pons to the ventromedial thalamus & then project to the whole cerebral cortex.

It receives collateral from the spinothalamic & the trigeminal thalamic pathways.

Disorders that distort normal anatomical relationships of the mid brain, thalamus, and cortex appear to impair arousal.

TERMINOLOGY

ConsciousnessConfusionDrowsinessStuporComa

CONSCIOUSNESS

It means the state of the patient’s awareness of self and environment and his responsiveness to external stimulation and inner need.

CONFUSION

Traditionally referred as “ CLOUDING OF SENSORIUM.”

It denotes inability to think with customary speed clarity and coherence accompanied by some degree of inattentiveness and disorientation.

Confusion results most often from process that influence the brain globally. Such as toxic or metabolic disturbance or a dementia.

DROWSSINESS

It is inability to sustain a wakeful state without application of external stimuli.

Slow arousal is elicited by speaking to patient or applying a tactile stimulus.

STUPOR

Stupor can be described a state in which the patient can be aroused only by vigorous and repeated stimuli.

Response to verbal command is either absent or slow and inadequate.

When left unstimulated, these patients quickly drift back into a sleep like state.

COMA

Coma is a deep sleep like stage from which patient can not be aroused to respond appropriately to stimuli even with vigorous stimulation.

The patient may grimace in response to painful stimuli and limbs may show stereotyped withdrawal response, but patient does not make localized responses.

COMMON CAUSES OF UNCONSCIOUSNESS

Head injuryCerebrovascular diseaseMeningoencephalitisCerebral abcessDiabetes melitus

Hypoglycemia Ketoacidosis HHS

Uremia

Hepatic failure Sepsis DrugsHypothermia Electrolyte imbalanceMyxoedema comaCerebral hypoxiaCardiac arrest

INITIAL MANAGEMENT OF UNCONSCIOUS PATIENT ON ARRIVAL

ABCDE approach:AirwayBreathingCirculation Disability Exposure

AIRWAY

Evaluate – is airway patent? Is there any trauma or foreign body obstruction in airway?

Patient with head injury may also have suffered a fracture of cervical vertebra, in which caution must be exercised during examining head neck.

If breathing is easy- oropharyngeal airway is sufficientIf respiration is shallow or labored or chance of aspiration

intubation is needed.Head tilt & chin lift maneuver.

BREATHING

Evaluate- is respiration adeuate? Is gas exchange adequate? Are breath sounds are adequate & symmetrical?

Must assure oxygenation& ventilation.Identify and immediately treat problems- pneumothorax,

airway obstruction,etc.

CIRCULATION

Is patient in shock? check pulses, heart rate, BP, capillary refill time

*remember hypotension is late sign of shock

Start treatment of shock Do not restrict fluid in comatose patient with inadequate

intravascular volume. Use isotonic solutions & blood , as indicated.

Don’t use hypotonic solutions to treat shock, particularly patient with coma or cerebral edema.

Identify life threatening hemorrhage & control it. Colloid has no role in volume replacement .

Types of shock: Hypovolaemic Obstructive Cardiogenic distributive

HISTORY

Inquire about- History of diabetes Hypertension Head injury Convulsions Alcohol or drug use Circumstances in which patient was found Medications in hospitalized patient like anesthetics, antiepileptic,

opiates, antidepressants, antipsychotics.

Onset of unconsciousness: Sudden onset- vascular origin especially brainstem stroke or SAH. Rapid progression from hemispheric signs to coma- intracerebral

hemorrhage. Protracted course- tumor, abscess, chronic SDH. Coma preceded by confusional or agitated state & without

lateralizing signs- metabolic cause.

GENERAL EXAMINATION

GENERAL EXAMINATION

Signs of trauma- Raccoon eyes Battle’s sign CSF rhinorrhea or otorrhea

Blood pressure- Hypertension suggests:

Hypertensive encephalopathy Intracerebral hemorrhage

Hypotension suggests: Myocardial infarction Septicemia Addison disease Alcohol or barbiturate poisoning Internal hemorrhage.

Temperature: Hypothermia suggests:

Alcohol or barbiturate intoxication Myxedema Advanced Tubercular meningitis Peripheral circulatory failure

Hyperthermia suggests-• Systemic infection• meningoencephalitis • heat stroke • anticholinergic drugs abuse

Pulse- bradycardia with periodic breathing and hypertension (Cushing Reflex) suggests raised ICP.

Skin inspection: • Rash• Excessive sweating

Odour of breath: • DKA• Hepatic encephalopathy

Evidence of any systemic illnessHeart-lung

Neurological examination

Asses level of consciousness: by GLASGOW COMA SCALE.

Signs of meningeal irritation-• Meningitis• SAH

Fundus:• Raised ICP• SAH• Hypertensive encphalopathy

Papilloedema

Subarachnoid Hemorrhage

Hypertensive retinopathy

Pupil size and response to lightOccular movementsPosture and limb movement:

Decorticate posture Decerebrate posture

Reflexes

Glasgow Coma Scale

Three components. Score derived by adding the score for each component.

Eye opening (4 points)Verbal Response(5 points)Best motor response(6 points)

Eye opening 4- spontaneous 3-to speech 2-to pain 1-none

Verbal response 5-oriented 4- confused conversation 3-inappropriate words 1-none

Best motor response 6-obeys 5-localizes 4-withdrawal 3-abnormal flexion 2-abnormal extension 1- none

Glasgow Coma Scale

Laboratory investigations

Lab investigations are done to confirm the provisional diagnosis and to exclude the differential diagnoses.

There are several investigations but the physician should be specific what investigations should be appropriate for the patient.

Detailed history and clinical examination will guide the physician to choose that investigations.

Chemical blood determinations are made routinely to investigate metabolic, toxic or drug induced encephalopathy.

Blood urea & Electrolytes Serum Creatinine Random blood glucose Drug levels Toxicological screen LFT Thyroid function test

Arterial blood gas analysis CBC Blood C/S Urine C/S Malaria screening

Imaging: in coma of unknown etiology CT or MRI must be performed to detect-

Ischemic stroke Hemorrhage Tumor & hydrocephalus

Lumbar puncture : to diagnose- Meningitis SAH

ECG

Treatment

Treatment should be focused according to cause. But whatever the cause, long term attention is required to maintain patient’s respiration, Circulation, skin, bladder & bowel function, seizure must be controlled and the level of consciousness should be regularly assessed. If patients condition is deteriorating or not improving patient should be shifted to ICU.

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