Management of unconscious patient
Özlem Korkmaz Dilmen
Associate Professor of Anesthesiology and
Intensive Care
Cerrahpasa School of Medicine
Learning Objectives
• Definition of unconsciousness
• Common causes
• Diagnosis and treatment of unconscious
patient
Definition
Unconsciousness is a state in which a
patient is totally unaware of both self and
external surroundings, and unable to
respond meaningfully to external stimuli.
A system of upper brainstem and thalamic neurons, the reticular activating system and its broad connections to the cerebral hemispheres maintain wakefulness.
Common Causes I• Interruption of energy substrate delivery
a. Hypoxia
b. Ischemia
c. Hypoglycemia
• Alteration of neurophysiologic responses of neuronal
membranes
a. Drug intoxication
b. Alcohol intoxication
c. Epilepsy
Common Causes II
• Abnormalities of osmolarity
a. Diabetic ketoacidosis
b. Nonketotic hyperosmolar state
c. Hyponatremia
• Hepatic encephalopathy
• Hypertensive encephalopathy
• Uremic encephalopathy
Common Causes III
• Hypercapnia• Hypothyroidism• Hypothermia• Hyperthermia
An unconscious case
• 46 years old, male• DM
• Unconscious
• A (Airway)
• B (Breathing)
• C (Circulation)
• D (Disability)
• E (Exposure)
First Aid
Airway - A
• Head tilt, chin lift
• Jaw trust
• Clearance (aspiration)
• Oral/Nasal Airway
• Intubation
Airway - A
Breathing - B
• Look, listen and feel
for NORMAL
breathing.
• Symmetry
• Breathing Sounds
• Tidal Volume
• Respiratory rate
Breathing - B
Abnormal breathing
• Occurs shortly after the heart stops
in up to 40% of cardiac arrests
• Described as barely, heavy, noisy or gasping
breathing
• Recognise as a sign of cardiac arrest
• Pulse
• Rate
• Rhytme
• Arterial Pressure
• Hypertension
• Hypotension
Circulation - C
Disability - D
• Disability is determined from the patient level of
consciousness according to the AVPU or GCS.
A for ALERTV for VOICEP for PAINU for UNRESPONSIVE to any stimulus
GLASGOW COMA SCALE
•I. Motor Response
6 - Obeys commands fully
5 - Localizes to noxious stimuli
4 - Withdraws from noxious
stimuli
3 - Abnormal flexion, i.e.
decorticate posturing
2 - Extensor response, i.e.
decerebrate posturing
1 - No response
•II. Verbal Response
5 - Alert and Oriented
4 - Confused, yet coherent, speech
3 - Inappropriate words and jumbled
phrases consisting of words
2 - Incomprehensible sounds
1 - No sounds
•III. Eye Opening
4 - Spontaneous eye opening
3 - Eyes open to speech
2 - Eyes open to pain
1 - No eye opening
Exposure an Environment - E
The patient’s clothes should be
removed or cut in an appropriate
manner so that any injuries can
be seen.
General Physical Examination
• History
• Neurologic examination
• The eye examination
• Fundoscopy
• Ventilatory pattern
History
• In many cases, the cause of coma is immediately evident;
- Trauma
- Cardiac arrest
- Drug ingestion
• In the reminder, historical information may be helpful.
.
Cirrhosis
Meningococcemic rashs
Evolution of neurologic signs in coma from a hemispheric mass lesion as the
brain becomes functionally impaired in a rostral caudal manner. Early and late
diencephalic levels are levels of dysfunction just above (early) and just below
(late) the thalamus.
Neck rigidity
Neck rigidity
• Bacterial meningitis
• Subarachnoid hemorrhage
Hepatic coma
The eye examination
Pupillary abnormality is one of the cardinal
features differentiating surgical disorders from
medical disorders. Pupillary abnormalities in
coma generally herald structural changes in
brain, whereas in metabolic coma such
abnormalities are not present.
Fixed and dilated pupils
Fixed and dilated pupils
• The terminal stage of brain death
• Atropine effect
Pinpoint pupils
Pinpoint pupils
• Narcotic overdose
• Bilateral pontine damage
Pupillary dilatation
Pupillary dilatation
Sudden lesion of the midbrain; ruptere of an
internal carotid artery aneurysm
Fundoscopic examination
Fundoscopic examination
• Subarachnoid hemorrhages
• Hypertensive ensefalopaty
• Increased inrtacranial pressure
Laboratory examination
Chemical blood determinations are made
routinely to investigate metabolic, toxic or drug
induced encephalopaties.-Electrolytes
-Calcium
-Blood urea nitrogen
-Glucose
-NH3
Laboratory examination
• Toxicological analysis is of great value in any
case of coma where the diagnosis is not
immediately clear.
• The presence of alcohol does not ensure that
alcohol is the cause of the altered mental
status. Other, life-threatening, causes must be
ruled out.
Imaging
• In coma of unknown etiology, CT or MRI
must be performed.
• Radiologically detectable causes of coma;
- Hemorrhage
- Tumor
- Hydrocephalus
Brain herniation
Electroencephalography
EEG is useful
in
unrecognized
seizures.
Lumbar puncture
• The use of LP in coma
is limited to diagnoses
of meningitis and
instances of suspected
subarachnoid
hemorrhage in which
the CT is normal.
Complaints Diagnosis Action
History of diabetes, use of oral
anti-diabetic or ingestion of
alcohol
* Hypoglycaemia • *Test blood for glucose using
test strip or glucose meter.
• Give IV Glucose
History of ingestion of
medication (tablets or liquid).
There may be smell of alcohol
or other substance on breath
Drug overdose.
e.g. Alcohol,
• Support respiration
• IV Glucose to prevent
hypoglycaemia.
In chronic alcoholics
• Precede IV glucose with IV
Thiamine, IV fluid
administration.
E.g. Paracetamol. • Gastric lavage, n-
acetylcysteine treatment if >
140 mg/kg body weight
ingested
Complaints Diagnosis Action
Presence or absence of history
of diabetes;
- polyuria, polydipsia
- hyperventilation
- gradual onset of illness
- evidence of infection
- Urine sugar and ketone
positive
- Blood glucose> 250 mg/dL
* Diabetic ketoacidosis • *Give Soluble Insulin and
Sodium Chloride 0.9% infusion
Fever, fits, headache, neck
stiffness, altered
consciousness etc
* Meningitis or Cerebral Malaria • *Treat with antibiotics and
quinine until either diagnosis
confirmed.
History of previous fits, sudden
onset of convulsions; with or
without incontinence.
* Epilepsy • *Give Diazepam, IV, to abort
fits and continue or start with
anti-epileptic drug treatment
Patient with hypertension or
diabetes; sudden onset of
paralysis of one side of body.
* Stroke • Check blood pressure and
blood glucose.
Patient with hypertension,
headaches, seizures
* Hypertensive encephalopathy • Check blood pressure
• If very high, give oral or
parenteral anti-hypertensives
Complaints Diagnosis Action
Thank you for your attention
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