Unconsciousness presentation 1

UNCONSCIOUSNESS

Soumya Ranjan Parida

PARTS OF BRAIN

INTRODUCTION• Loss or lack of consciousness.• Alteration of mental state. Complete or near complete lack of

responsiveness to people and other environmental stimuli.

Comatose state is an illustration of unconsciousness.

DEFINITIONUnconsciousness is a state in which:-• Unable to responds to people and

activities.• Lacking awareness and the capacity for

sensory perception.• Temporarily lacking consciousness.

• Without conscious control.• Not awareness of one’s actions,behaviour

etc.• Lacking normal sensory awareness of the

environment.• Without conscious volition.• Unconsciousness can be brief, lasting

for a few seconds to an hour or few hours or longer.

To produce unconsciousness, a disorder must-

o Disrupt ascending RAS extends length of brain stem and up in to the thalamus .

o Disrupt the function of both cerebral hemisphere.

o Metabolically depress over all brain function, as in drug overdose.

COMA

Coma is a state of sustained unconscious in which the patient:-

• Does not respond to verbal stimuli.• May have varying painful stimuli.• Does not move voluntarily.• Altered respiratory patterns.• Altered papillary response to light.• Does not blink.

• In general the longer coma lasts, its irreversible due to a permanent disorder in the brain structure.• The longer the coma, the higher the mortality rates, and poorer the neurologic outcome.

TYPES OF UNCONSCIOUSNESS:- Stupor: - State of semiconsciousness in

which person responds to external stimuli or loud noise or painful stimuli i.e., pricking or pinching.

Somnolent :-State when person feels drowsy or sleepy and will responds only if spoken to directly.

Excitatory :- Patient does not respond to

but disturb by sensory stimuli i.e., bright light, noise and sudden movement.

Deep coma :-Complete loss of consciousness. Person is aware of himself and the environment and cannot be aroused if he is in deep coma.

TYPES OF COMA• Light coma:-Spontaneous and evoked

movement.

• Deep coma :-Heart rate is slow and respiratory rate is fast and the depth is increased.

• Premoribund :-Rhythm is periodic, pulse is irregular and BP rises.

• Moribund :-Apnoeic respiration, pupil dilated and fixed; pulse rates beats faster and BP falls.

ETIOLOGY AND RISK FACTOR

CLINICAL MANIFESTATION

PATHOPHYSIOLOGYConsciousness is a complex function controlled by RAS.RAS begin in the medulla as reticular formation.Reticular formation connect to RAS located in the midbrain, connects to the hypothalamus and thalamus.Integrated pathway connects to the cortex via thalamus and to the limbic

system via hypothalamus.

Reticular formation produces wakefulness where as RAS are responsible for awareness of self and

environment .Disorder that affect any part of

RAS can produce coma .To produce coma a disorder must

affect both cerebral hemisphere and

the brain stem.

DIAGNOSTIC FINDINGi. Laboratory test .ii. CT or MRI Scan.iii. Lumbar puncture.iv. EEG.

TEST FOR ABNORMAL REFLEXa) OCULOCEPHALIC RESPONSE :- Also known as Doll’s eye reflex. Movement of eye in the opposite

direction that in which head is moved . Test can be performed only in

unconscious patient. Presence of Doll’s eye indicate brain

stem function is preserved . Brain stem in a comatose patient may be

functioning in the absence of Doll’s eye reflex.

Eg;If the eyes moves to the right when the head is rotated to the left &vice versa- Doll’s eye is present.

b) OCULOVESTIBULAR :- Performed to test cranial nerve

iii,iv,vi,viii. Nystagmus is the involuntary

oscillation of the eye ball. It may be horizontal, vertical and

oblique . Absence of an oculovestibular

support the diagnosis of brain death.

Test performed only for comatose patient .

MANGAMENT OF UNCONSCIOUSNESS

FIRST AID:- The most important function of the first

aid is to ensure that patient air passage remains open and clear.

Take note of any alteration in the state of unconsciousness either improving or deteriorating.

Suppose if the patient is unresponsive no breathing only gasping.

Activate emergency response and get defibrillator .

Check pulse and high quality CPR improves a victim’s chance of survival.

The critical characteristics of high quality CPR include:Start compression within 10 sec. of recognition of cardiac arrest.Push hard ,push fast: Compress at a rate of 100beats/min with a depth of at least 2 inches(5cm) for adult and children, approximately 1 inch 1/2 (4 cm) for infant.Allow complete chest recoil after each compression.Minimize interruption in compression.Give effective breaths that make the chest rise.Avoid excessive ventilation.Begin cycles of 30:2

AED/Defibrillator arrives. Check rhythm shock able give 1 shock

and resume CPR immediately for 2 min. If rhythm not shockable resume CPR

immediately for 2 min. Check rhythm every 2min, continue ALS

providers take over or victim start to move.

MEDICAL MANAGEMENT:- The goal of medical management are to

preserve brain function and to prevent additional brain injury.

The primary focus is on maintaining the supply oxygen and glucose to the brain .

The patient circulation, airway and breathing must be maintained.

REVERSE COMMON CAUSES OF COMA

The immediate intervention for the patient in a coma include treatment of common causes of coma .For comatose patient who appear malnourished, wernicke’s encephalopathy may occur secondary to alcohol abuse.

The patients are commonly given thiamine for prevention especially if they are given glucose.

If the patient is having lorzepam repetitive seizure, coma and brain damage can follow. The patient iv diazepam, or lorazepam to stop the seizure.

If the patient is not intubated ,closely monitor the airway because of these depressants effect of these medicine.

If cerebral oedema is present ,osmotic diuretic may used to promote shifting of extracellular brain fluid back in to the plasma.

Steroid barbiturate (neuromuscular blocking )decrease intracranial pressure.

If the infection is suspected patient has shivering then ICP increases.

Use of vasoactive agents may be required to keep systolic pressure at 100mmHg or the mean systolic BP above 80 mmHg.

Promote cerebral perfusion.

SURGICAL MANAGEMENT Airway. Position. Pain and sedation . Temperature. Cornea. Food and fluid. Bladder. Anticonvulsant therapy.

NURSING MANAGEMENT Environment and family. Physical care. Observation. Convalescence. End of life care.

Environment and family :

Physical care :

Observation:

Convalescence :

End of life care :

Communication :-

Physical comfort :-

Mental comfort :-

Spiritual comfort :-

Financial need :-

NURSING DIAGNOSIS Ineffective airway clearance related to

upper airway obstruction by tongue and soft tissue, inability to clear respiratory secretion.

Ineffective thermoregulation related to damage to hypothalamic centre.

Self care deficit related to impairment of musculoskeletal impairment.

Imbalanced nutrition related to poor appetite and unconsciousness.

Interrupted family process related to uncertain future or impending death of a family member.

Risk for fluid volume deficit related to inability to ingest fluid.

Risk for aspiration related to lack of effective airway clearance and loss of gag reflex.

Risk for skin integrity related immobility.

Risk for infection related to external factor.

Risk for injury related to lack of safety.

COMPLICATION • Respiratory function:- Inability to maintain patent airway means

that aspiration of fluid, oral secretion, blood in presence of trauma all this lead to chest infection.

• Supine position comprise the mechanics of breathing ,flat position causes reduction in residual and functional residual capacity of lung leads to complete collapse of lung (atlectasis)and poor ventilation.

• Venous stasis decrease vasomotor tone. Pressure in blood vessel hypercoaguable state leads to venous thromboembolism, pulmonary embolism.

• Pressure ulcer.• Altered metabolism: increased excretion of

calcium from bone has a reduced weight.

CONCLUSION The comatose client may remain in

hospital for a few days, month or year. Some comatose patient awaken may make a complete recovery while in the hospital. Therefore some expected outcomes have a brief time frame (e.g.; airway obstruction) whereas other are prolonged, requiring frequent re-evaluation.

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