1. Approach to

2. Contents Clinical Evaluation History Examination Lab Evaluation
Management

3. Basics
Wakefulness depends on the integrity of both cerebral hemi- spheres and the ascending reticular activating formation of the brain stem.

4. Cont..
The management of an unconscious patient is never an easy task in clinical practice
The duty of physician is
Arrive at diagnosis
Predict the eventual outcome

6. History

7. Onset of coma
(abrupt, gradual)
ii) Recent complaints
( headache, depression, focal weakness, vertigo )
iii) Recent injury
iv) Previous medical illness
( diabetes,uraemia, heart disease )
v) Access to drugs
( sedatives,psychotropic drugs )

8. Examination

9. General physical Examination
i) Vital signs
ii) Evidence of trauma
iii) Evidence of acute or chronic system illness
iv) Evidence of drug ingestion ( needle marks alcohol breath )
v) Nuchal rigidity (examine with care)

10. Neurological Examination

11. State of consciousness
Obtundation; responds-to verbal stimuli although slow and inappropriate.
Stupor; the subject can be aroused only by vigorous and repeated noxious stimuli.
Coma; unarousable and unresponsive.
Stupor; the subject can be roused
only by vigorous and repeated
noxious stimuli.

12. Respiratory pattern
a ) Hyperventilation - midbrain and upper pons lesion
metabolic diseases e.g. hepatic coma, diabetes and generalised raised intracranial pressure in its early stages.
( b ) Hypoventilation - medullary, upper cervical spinal lesion
Drug overdose and later stages of cerebral herniation.
( e ) Cheyne-Stoke respiration – usually diencephalic lesion
central transtentorial herniation and obstructive hydrocephalus.
( d ) Ataxic respiration (completely irregular breathing)
brain-stem dysfunction of a diffuse nature

13. Pupillary size and reaction
Medium to dilated symmetrical pupils fixed to light structural disease of the brain stem.
Small symmetrical pupils reactive to light
metabolic diseases and drug overdose.
Unequal pupil fixed to light
intracranial mass lesion producing 3rd nerve palsy e.g in unilateral uncal herniation.

14. Eye movements
Vestibulo-ocular reflexes – douching of one ear with cold water produces ipsi-lateral deviation of both eyes with a contralateral quick phase nystagmus lasting for 1—2 minutes. Use of hot water produces the opposite effect i.e. contralateral deviation with ipsilateral quick phase nystagmus. Bilateral douching with cold water gives rise to downward deviation with upward nystagmus and with hot water the opposite response. Absence or abnormal response indicates brain-stem dysfunction.
Oculo-cephalic reflexes (Doll's eye movement ) - Normal response consist of deviation of both eyes to the opposite direction of head rotation. Again absence or abnormal response indicates brain-stem dysfunction.

15. Motor Responses
This is elicited by applying peripheral noxious stimuli e.g. pinching of limbs rubbing the sternum to elicit pain.
( a ) Appropriate response – brushing away the source of stimulus.
{ b ) Inappropriate response - decerebrate or decorticate rigidity. Motor response is also of localising value. Paralysed limb will show no response and presence of hemiplegia can therefore be evident. Decerebrate rigidity indicates brain-stem damage and if bilateral is usually associated with a very poor prognosis. Complete flaccidity with no response to noxious stimuli is often indicative of severe central nervous system depression due to drug overdose.

16. Laboratory Evaluation

17. Supratentorial lesions
Skull radiograph
Computerised tomographic scan CTscan)
Carotid angiography
EEG ( electroencephalogram )

18. Infratentorial lesions
Skull radiograph
CT scan
Vertebral angiography
EEG
Ventriculography

19. Diffuse neuronal lesions
Examination of CSF ( cerebro spinal fluid )
Serum glucose, calcium, Na, K, magnesium
Blood gases and PH
Liver and renal functions
Drug levels

20. Management

21. Initial Management
Airway
Breathing
Circulation
Deformity
Exposure

22. Definitive Management
In general, management of the comatose patient depends on the cause. However, while the patient is undergoing evaluation, it is essential to :
pressure area care
care of the mouth, eyes and skin
physiotherapy to protect muscles and joints
risks of deep vein thrombosis
risks of stress ulceration of the stomach
nutrition and fluid balance
urinary catheterization
monitoring of the CVS
infection control
maintenance of adequate oxygenation, with the assistance of artificial ventilation

23. You are in emergency department when an unconscious patient land in emergency with B.P 90/50 pulse 92/min and attendants tell u that the patient suddenly fell unconscious, how will you approach ?

24. APPROACH
ABC
Immediate management
Examination
History
Investigations

25. ABC

26. Immediate management Maintain i.v line, oxygen inhalation
Blood sample for RBS
Control seizures
Consider i.v glucose, thiamine, naloxone, flumazenil

27. Examination

28. Vitals CONTD. 1.Pulse tachycardia Hypovolemia/haemorrhage hyperthermia
Intoxication
bradycardia
Raised intracranial pressure
Heart blocks

29. CONTD. 2.Temperature increased Sepsis Meningitis ,encephalitis
Malaria ,Pontine haemorrhage
Decreased
Hypoglycemia
Hypothermia (less than 31 C)
Myxedema
Alcohol, barbiturate ,sedative or phenothiazine intoxication.

30. CONTD. 3.Blood pressure increased Hypertensive encephalopathy
Cerebral haemorrhage
Raised intracranial pressure
Decreased
Hypovolemia /hgr
Myocardial infarction
Intoxication/poisoning
Profound hypothyroidism, Addisonian crisis

31. Increased(tachypnae)
CONTD.
4.Respiratory rate
Increased(tachypnae)
Pneumonia
Acidosis (DKA, renal failure)
Pulmonary embolism
Respiratory failure
Decreased
Intoxication/poisoning

32. Skin petechial rash CONTD. Meningococcal meningitis Endocarditis
Sepsis,thrombotic thrombocytopenic purpura
Rickettsial infection
RMS (rocky mountain spotted fever)

33. Multiple injection marks
CONTD.
Multiple injection marks
Drug addiction
Acute endocarditis
Hepatitis B /C with encephalopathy
HIV

34. Neurological assessment;
CONTD.
Neurological assessment;
General posture
Level of conciousness

35. Posture; CONTD. Lack of movements on one side Intermittent twitching
Multifocal myoclonus
DECORTICATION
DECEREBRATION

36. Level of conciousness CONTD. Glasgow coma scale (GCS)
Best motor response
Best verbal response
Eye opening
GCS score 3 –severe injury
less than or equal to 8 – moderate injury
9 to 12 – minor injury

37. CONTD.
An abbreviated coma scale is used in the assessment of critically ill patient (primary servey)
AVPU
A –alert
V – respond to voice stimulus
P – respond to pain
U - unresponsive

38. Brainstem reflexes Pupillary responses to light
Spontaneous and elicited eye movements
Corneal responses
Respiratory movements

39. CONTD. Ocular movements
Conjugate deviation of eyes to a side – ipsilateral hemisphere frontal leison or contralateral pontine leison. Rarely eyes may turn paradoxically away from the side of deep hemisphere leison (WRONG-WAY EYES)
Downward conjugate deviation of eyes – mesencephalic leison.

40. CONTD.
Eyes turn down and inward in – thalamic hgr and upper midbrain leison.
Ocular bobbing – is diagnostic of pontine hgr.
Ocular dipping - indicates diffuse cortical anoxic damage.
Dysconjugate ocular deviation – brainstem leison.

41. CONTD.
Oculocephalic reflex (Doll’s eyes response) – brisk in cortical depression ,lost in brainstem leison.
Oculovestibulo responses –two components
1.Conjugate ocular movement – loss in brainstem damage.
2.Nystagmus – loss in damage to cerebral hemisphere

42. CONTD. Pupillary changes;
Sr no
pupils
causes 1
B/L Pin-point pupils ( less than 1mm)but responsive
Opiates poisoning ,extensive pontine hgr. 2
B/L small pupils but responsive
B/L diencephalon involvement or destructive pontine leison 3
B/L slightly small pupils(1 to 2.5 mm) but responsive
Metabolic encephalopathies ,deep B/L hemisphere leison or thalamic hgr. 4
B/L dilated and fixed
Severe midbrain damage, Overdose of atropine,scopolamine,
glutethemide.

43. CONTD. Sr. no. Pupil cause 6 U/L small pupil Horner syndrome 5
Ipsilateral dilated pupil with no direct or consensual reflexes
Compression of 3rd cranial nerve e.g, uncal herniation 7
U/L small and irregular pupil
unresponsive
Leison in pretectal area of midbrain

44. CONTD. Respiratory movements
Has less localizing value then other brainstem reflexes.
Cheyen-stokes respiration(classic cyclic form ending with a brief apneic period – B/L hemisphere damage or metabolic depression.
Rapid ,deep breathing (Kussmaul) –in metabolic acidosis and in pontomesencephalic leison.

45. Neck rigidity;
Meningitis
Subarachnoid haemorrhage

46. Fundoscopy Raised intracranial pressure Hypertensive changes
Subarachnoid haemorrhage
Diabetic retinopathy

48. History Onset of the symptoms Antecedent symptoms Use of medications
Chronic liver ,kidney ,lung or heart disease

49. CAUSES OF UNCONCIOUSNESS

50. Causes of unconciousness
Metabolic
Drugs, poisoning e.g CO ,alcohol
Hypoglcemia, hyperglycemia (keto acidoti or HONK)
Hypoxia, carbondiaoxide narcosis (COPD)
Septicemia
Hypothermia
Myxedema ,addisonian crisis
Hepatic / uremic encephalopathy

51. CONTD. Neurological Trauma
Infections – meningitis, encephalitis, malaria, typhoid, rabies, trypanosomiasis.
Tumours – cerebral / meningeal tumors
Vascular – subdural / subarachnoid hgr, stroke, hypertensive encephalopathy
Epilepsy – nonconvulsive status / postictal state

52. Immediate investigations
RBS
Blood CP and ESR
LFTs
Urea and Creatnine
Blood and urine cultures

53. Other investigations CRP ABGs Toxic screen , drug levels
Lumbar puncture and CXR
CT scan

54. Stabilize cervical spine
Summary
ABC of life support
Oxygen and I.V access
Stabilize cervical spine

55. Consider I.V glucose, thiamine, naloxone, flumazenil
CONTD.
Blood glucose
Control seizures
Consider I.V glucose, thiamine, naloxone, flumazenil

56. CONTD. Brief examination and obtain history Investigate
Reassess the situation and plan further

57. Take home message
Early management
Prompt diagnosis

58. MCQ Pupillary changes in opiate poisoning 1.B/L pinpoint
2.U/L pin point
3.B/L dilated

59. Answer
1. B/L pin point

60. MCQ Myxoedema coma seen in 1.Euthyroid state 2.Hyperthyroid state
3. hypothyroid state

61. Answer
3. hypothyroid state

62. THANK YOU

63. Thank You