Dr. Ahmed Al Montasir

• Causes• Bilateral cortical diseases/processes

– Trauma – head injury – Hypoxia – HIE, sinus thrombosis, CVA – Infection – cerebral abscess, meningitis, encephalitis – Haemorrhage – SAH, SDH – Metabolic – DKA, HHS, hypo or hyper Na/K,

hypoglycaemia – Organ failure – liver or renal – Postictal – Endocrine – thyroid storm, myxoedema, Addison

crisis – Drugs – opiates, alcohol, opioid, alcohol, cocaine,

benzodiazepine, antidepressant • Brainstem disorder ~ Supratentoral/infratentoral

lesions à SDH, EDH, ICB

• A- Apoplexy• E-Epilepsy

• I-Infection (Encephalitis)• O-Opium• U-Uremia

• D-DK• A-Accident

• M-Metabolic

• Approach• Priority should be given to ABC resuscitation and

perform examination simultaneously, then: -• Obtain quick history from witness

– Onset – abrupt/graduali. Acute (sec/min)– CVA, cardiac arrest, SDH, head injuryii. Subacute (min-hrs) – sepsis, infections, drug, hypo

– Recent complaints – headache, depress, weakness, vertigo

• Recent injury

• Previous medical illness

• ExaminationExamination• Vitals – T, PR, BP, RR • Skin petechial rashes, ecchymosis

(meningoencephalitis) • Neurological assessment

i. Posture * Lack of movement of one side * Intermittent twitching * Multifocal myoclonus * Decortication * Decerebration

• ii. Level of consciousnessiii. Neck rigidityiv. Pupil sizes – Horner Syndrome (ptosis, myosis, anhydrosis and enophthalmus), atropine overdose, opioid poisoning, ICB etc

• State of awareness can be assessed by GCS score

• 15 conscious • 14-8 impaired/delirious • 3-8 unarousable • According to severity of injury:

*Minor injury score 13-15*Moderate score 9 -12*Severe injury ≤ 8

GCS

• Eye opening

• 4- spontaneous opening3 open on speech/call2 open on pain1 not open

GCS

• Verbal response

• 5- oriented speech4 confused3 inappropriate2 incomprehensible1 none

GCS

• Motor response

• 6 – obey command5 localised pain4 withdrawal to pain3 decorticate (abnormal flexion of limb)2 decerebrate (abnormal extension of limb)1 not responding

• Pupillary Abnormalities (list causes)Pupillary Abnormalities (list causes)

• Equal size:

• Pinpoint

• Dilated

• Unequal size:

• Equal size

• Pinpoint

• opiates/organophosphates, pontine lesion

• Dilated

• hypoxia, anticholinergics, alcohol, metabolic

• Unequal size

• Dilated + Fixed

• Uncal herniation,

• IIIrd nerve palsy

• 20% of population have unequal pupils

• ExaminationExamination• v.      Funduscopyvi.      Brainstem reflex – pupil reflexesvii.      Corneal reflexviii.      Doll’s eye reflex (eye move to opposite side of movement so it always goes to centre) – if negative à brainstem injured

• 4. Racoon eyes ~ basal skull #

• ExaminationExamination• 5. Otorrhoea/rhinorrhoea6. Nails, dxt marks7. Breathingi.      Cheyne-Stroke – rapid, shallow with periodic apnoeic episodes à heart failure, strokes, traumatic brain injuries, tumours, CO poisoning, morphine, toxic metabolic encephalopathyii.      Kussmaul – deep laboured breathing (usually met acidosis) e.g. DKA, renal failureiii.      Biot breathing – cluster pattern ~ pontine malfunctioniv.      Gasping – severe hypoxia

Investigations

• CBC• RBS• ECG• Serum electrolytes• Serum creatinine• ABG• CXR• CT brain

Key to managing the unconscious patientKey to managing the unconscious patient

• Support / protect ABCs

• Diagnose cause

• – History, focussed examination, focussed

• investigations

• Reverse/ treat if possible

AlgorithmAlgorithm

• ABC of life support↓

• Oxygen and I.V access↓

• Stabilize cervical spine↓

• Blood glucose↓

• Control seizures↓

• Consider I.V glucose, thiamine, naloxone, flumazenil↓

• Brief examination and obtain history↓

• Investigate↓

• Reassess the situation and plan further