Management of Unconscious Patient
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Management of unconscious patient
Özlem Korkmaz Dilmen
Associate Professor of Anesthesiology and
Intensive Care
Cerrahpasa School of Medicine
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Learning Objectives
• Definition of unconsciousness
• Common causes
• Diagnosis and treatment of unconscious
patient
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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.
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A system of upper brainstem and thalamic neurons, the reticular activating system and its broad connections to the cerebral hemispheres maintain wakefulness.
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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
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Common Causes II
• Abnormalities of osmolarity
a. Diabetic ketoacidosis
b. Nonketotic hyperosmolar state
c. Hyponatremia
• Hepatic encephalopathy
• Hypertensive encephalopathy
• Uremic encephalopathy
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Common Causes III
• Hypercapnia• Hypothyroidism• Hypothermia• Hyperthermia
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An unconscious case
• 46 years old, male• DM
• Unconscious
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• A (Airway)
• B (Breathing)
• C (Circulation)
• D (Disability)
• E (Exposure)
First Aid
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Airway - A
• Head tilt, chin lift
• Jaw trust
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• Clearance (aspiration)
• Oral/Nasal Airway
• Intubation
Airway - A
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Breathing - B
• Look, listen and feel
for NORMAL
breathing.
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• Symmetry
• Breathing Sounds
• Tidal Volume
• Respiratory rate
Breathing - B
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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
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• Pulse
• Rate
• Rhytme
• Arterial Pressure
• Hypertension
• Hypotension
Circulation - C
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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
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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
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Exposure an Environment - E
The patient’s clothes should be
removed or cut in an appropriate
manner so that any injuries can
be seen.
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General Physical Examination
• History
• Neurologic examination
• The eye examination
• Fundoscopy
• Ventilatory pattern
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History
• In many cases, the cause of coma is immediately evident;
- Trauma
- Cardiac arrest
- Drug ingestion
• In the reminder, historical information may be helpful.
.
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Cirrhosis
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Meningococcemic rashs
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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.
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Neck rigidity
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Neck rigidity
• Bacterial meningitis
• Subarachnoid hemorrhage
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Hepatic coma
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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.
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Fixed and dilated pupils
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Fixed and dilated pupils
• The terminal stage of brain death
• Atropine effect
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Pinpoint pupils
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Pinpoint pupils
• Narcotic overdose
• Bilateral pontine damage
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Pupillary dilatation
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Pupillary dilatation
Sudden lesion of the midbrain; ruptere of an
internal carotid artery aneurysm
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Fundoscopic examination
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Fundoscopic examination
• Subarachnoid hemorrhages
• Hypertensive ensefalopaty
• Increased inrtacranial pressure
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Laboratory examination
Chemical blood determinations are made
routinely to investigate metabolic, toxic or drug
induced encephalopaties.-Electrolytes
-Calcium
-Blood urea nitrogen
-Glucose
-NH3
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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.
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Imaging
• In coma of unknown etiology, CT or MRI
must be performed.
• Radiologically detectable causes of coma;
- Hemorrhage
- Tumor
- Hydrocephalus
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Brain herniation
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Electroencephalography
EEG is useful
in
unrecognized
seizures.
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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.
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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
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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
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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
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Thank you for your attention