Management of Unconscious Patient

Management of
unconscious patient
zlem 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
First Aid
A (Airway)
B (Breathing)
C (Circulation)
D (Disability)
E (Exposure)
Airway - A
Head tilt, chin lift

Jaw trust
Airway - A
Clearance (aspiration)
Oral/Nasal Airway
Intubation
Breathing - B
Look, listen and feel
for NORMAL
breathing.
Breathing - B
Symmetry
Breathing Sounds
Tidal Volume
Respiratory rate
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
Circulation - C
Pulse
Rate
Rhytme
Arterial Pressure
Hypertension
Hypotension
Disability - D
Disability is determined from the patient level of
consciousness according to the AVPU or GCS.
A for ALERT
V for VOICE
P for PAIN
U for UNRESPONSIVE to any
stimulus
GLASGOW COMA SCALE

I. Motor Response
II. Verbal Response
6 - Obeys commands fully
5 - Alert and Oriented
5 - Localizes to noxious stimuli
4 - Confused, yet coherent, speech
4 - Withdraws from noxious stimuli
3 - Inappropriate words and jumbled

phrases consisting of words
3 - Abnormal flexion, i.e.

decorticate posturing
2 - Extensor response, i.e.
decerebrate posturing
1 - No response
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 patients 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
History of diabetes, use of oral
Diagnosis
* Hypoglycaemia
Action
*Test blood for glucose using
anti-diabetic or ingestion of
test strip or glucose meter.
alcohol
Give IV Glucose
History of ingestion of
Drug overdose.
Support respiration
medication (tablets or liquid).
e.g. Alcohol,
IV Glucose to prevent
There may be smell of alcohol
hypoglycaemia.
or other substance on breath
In chronic alcoholics
Precede IV glucose with IV
Thiamine, IV fluid
administration.
E.g. Paracetamol.
Gastric lavage, nacetylcysteine treatment if >

140 mg/kg body weight
ingested
Complaints
Diagnosis
Action
Presence or absence of history * Diabetic ketoacidosis
*Give Soluble Insulin and
of diabetes;
Sodium Chloride 0.9% infusion
- polyuria, polydipsia
- hyperventilation
- gradual onset of illness
- evidence of infection
- Urine sugar and ketone
positive
- Blood glucose> 250 mg/dL
Fever, fits, headache, neck
* Meningitis or Cerebral Malaria *Treat with antibiotics and
stiffness, altered
quinine until either diagnosis
consciousness etc
confirmed.
History of previous fits, sudden * Epilepsy
*Give Diazepam, IV, to abort
onset of convulsions; with or
fits and continue or start with
without incontinence.
anti-epileptic drug treatment
Complaints
Patient with hypertension or

diabetes; sudden onset of
Diagnosis
* Stroke
Action
Check blood pressure and

blood glucose.
paralysis of one side of body.
Patient with hypertension,

headaches, seizures
* Hypertensive encephalopathy Check blood pressure

If very high, give oral or
parenteral anti-hypertensives
Thank you for your attention

Management of Unconscious Patient

Uploaded by

Copyright:

Available Formats

Management of Unconscious Patient

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Management of Unconscious Patient

Uploaded by

Copyright:

Available Formats

Management of

Common Causes III

Head tilt, chin lift

Described as barely, heavy, noisy or gasping

Recognise as a sign of cardiac arrest

GLASGOW COMA SCALE

II. Verbal Response

6 - Obeys commands fully

5 - Alert and Oriented

5 - Localizes to noxious stimuli

4 - Confused, yet coherent, speech

4 - Withdraws from noxious stimuli

3 - Inappropriate words and jumbled

3 - Abnormal flexion, i.e.

General Physical Examination

Evolution of neurologic signs in coma from a hemispheric mass lesion as the

The eye examination

Fixed and dilated pupils

Fixed and dilated pupils

case of coma where the diagnosis is not

alcohol is the cause of the altered mental status.

History of diabetes, use of oral

*Test blood for glucose using

test strip or glucose meter.

medication (tablets or liquid).

There may be smell of alcohol

or other substance on breath

Gastric lavage, nacetylcysteine treatment if >

Presence or absence of history * Diabetic ketoacidosis

*Give Soluble Insulin and

Sodium Chloride 0.9% infusion

* Meningitis or Cerebral Malaria *Treat with antibiotics and

quinine until either diagnosis

History of previous fits, sudden * Epilepsy

*Give Diazepam, IV, to abort

onset of convulsions; with or

fits and continue or start with

anti-epileptic drug treatment

Patient with hypertension or

Check blood pressure and

paralysis of one side of body.

Patient with hypertension,

* Hypertensive encephalopathy Check blood pressure

Thank you for your attention

You might also like