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