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 Hypoxia Ischemia Hypoglycemia Alteration of neurophysiologic responses of neuronal membranes Drug intoxication Alcohol intoxication Epilepsy

Common Causes II Abnormalities of osmolarity Diabetic ketoacidosis Nonketotic hyperosmolar state 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 Arterial Pressure Rate Rhytme 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 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

Complaints Diagnosis Action 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

Thank you for your attention