1. APPROACH TO THE UNRESPONSIVE PATIENT GREGORY MICK D.O.,F.A.C.O.S CENTRAL WASHINGTON NEUROSCIENCE CLINIC and Don Hudson, D.O., FACEP/ACOEP

2. INITIAL CONSIDERATIONS THE UNRESPONSIVE PATIENT, ESPECIALLY WITH A HISTORY OF TRAUMA, PRESENTS US WITH A STRESSFUL AND CHALLENGING SITUATION THERE ARE FEW SURVIVABLE COMPLICATIONS OF HEAD INJURY THAT WILL KILL YOUR PATIENT IN THE FIRST FEW HOURS. MANY OTHER PROBLEMS CAN, SUCH AS : CARDIAC TAMPONADE, PNEUMOTHORAX, LACERATIONS OF MAJOR ABDOMINAL ORGANS, FRACTURES- ESPECIALLY PELVIC FRACTURES

3. INITIAL CONSIDERATIONS cont. APPROPRIATE TRIAGE INCLUDES ABC’s SECONDARY BRAIN INJURY PREVENTABLE SEQUELAE OF INADEQUATE OXYGENATION HYPOTENSION ALMOST ALWAYS IS DUE TO INJURY OTHER THAN HEAD INJURY CUSHING PHENOMENON INCREASE IN ICP RESULTS IN DECREASED HR DECREASED RESPIRATIONS MUST ALWAYS ASSUME CERVICAL INJURY PRESENT

4. BASIC NEUROANATOMY RETICULAR ACTIVATING SYSTEM FIBERS ORIGINATING IN BRAINSTEM,SPREADING UPWARD INTO THE CEREBRAL HEMISPHERES RESEMBLES A BOUQUET OF FLOWERS STRUCTURE MOST RESPONSIBLE FOR CONSCIOUSNESS GLOBAL vs. LOCALIZED INSULT DUE TO THE ANATOMICAL DESIGN OF RAS, LESIONS MUST AFFECT ALL OF THE FIBERS IN ORDER TO CAUSE COMA

5. BASIC NEUROANATOMY cont. TOXIC ENCEPHALOPATHY DRUG OVERDOSE DRUG REACTIONS ENVIRONMENTAL EXPOSURES METABOLIC ENCEPHALOPATHY DIABETES HEPATIC FAILURE SEPSIS MENINGITIS BRAIN METABOLISM BRAIN UTILIZES ONLY GLUCOSE,GLUCONEOGENESIS OF NO USE

6. BEDSIDE CLINICAL EVALUATION GROSS OBSERVATION WATCH PATIENT RESPONSE TO INTUBATION (gag) WATCH EXTREMITIES FOR MOVEMENT(IV START) PALPATE SCALP OBSERVE FOR ECHYMOSIS (BATTLE’S SIGN,RACOON EYES) FACIAL ASYMMETRY(CRANIAL NEUROPATHY) EPISTAXIS HEMOTYMPANUM

7. BEDSIDE CLINICAL EVAL cont. LEVEL OF CONSCIOUSNESS VERBALIZATION ORIENTATION APHASIA FLUENTvsNON-FLUENT PAIN RESPONSE LOCALIZED vs. GENERALIZED WITHDRAWAL POSTURING RESPONSE(FLEXIONvs EXTENSION EYE MOVEMENT DOLL’S EYE (INDICATES MID-BRAIN FUNCTION) CALORIC TESTING

8. BEDSIDE CLINICAL EVAL cont. PUPILLARY SIZE & REACTION CORNEAL REFLEX( CN V) GAG REFLEX ( CNIX & CNXII) MUSCLE STRENGTH & TONE DEEP TENDON REFLEXES BABINSKI & HOFFMAN SIGNS

9. GLASCOW COMA SCALE Pts BEST EYE BEST VERBAL MOTOR 6 - - OBEYS 5 - ORIENTED LOCALIZES 4 SPONTANEOUS CONFUSED WITHDRAWS 3 TO SPEECH INAPPROPRIATE FLEXOR 2 TO PAIN INCOMPREHENSIBLE EXTENSOR 1 NONE NONE NONE

10. Lab and X-ray LABORATORY EVALUATION CBC, CHEM PROFILE, ABG, URINE & SERUM TOXICOLOGY, UA, ECG, CXR, APPROPRIATE C&S RADIOLOGY EVALUATION C-SPINE X-RAY CT OF HEAD CT OF QUESTIONALE SPINE X-RAYS

11. Therapeutic Interventions MAINTAIN C-COLLAR UNTIL C-SPINE CLEARED BY PHYSICIAN ESTABLISH AIRWAY ETT vs. TRACHEOSTOMY ARTIFICIAL RESPIRATION (MAINTAIN NORMAL pCO2) MAINTAIN ADEQUATE BP CONTROL ICP/CPP CPP=MAP-ICP NALOXONE MANNITOL/FUROSEMIDE NIMODIPINE CORTICOSTEROIDS ???? SZ PREVENTION GLUCOSE

12. Your Worries Pre-hospital care can be a challenge Always assume the worse, c-spine Fx, blood loss, cardiac event, suicide gesture, metabolic problems or intra-cranial event