Approach to an unconscious patient-PPT.ppt
- 1. APPROACH TO AN UNCONSCIOUS PATIENT Prof. M.A. Kashem Khandaker Professor of Medicine, DMCH
- 2. What is Consciousness? • Consciousness is regarded as a state of awareness self and surroundings. • Consciousness has two components: content and arousal. • Content is controlled by the cerebral hemispheres (also called cerebral cortex, or grey matter). It is marked by purposeful motor function and the use of language. • Arousal is level of consciousness. Patients can be awake without being aware - the vegetative state that we see, for example, in patients that have survived brain hypoxia with diffuse cortical injury. However, they must be awake to be aware - that is, content cannot exist without arousal.
- 3. What is Coma? Coma: It is the absence of any psychologically understandable response to external stimuli or inner need. COMA= NO SPEECH, NO EYE OPENING, NO MOTOR RESPONSE
- 4. Causes of Unconsciousness Intracranial: Trauma- Diffuse white matter injury Haematoma – Extradural, Subdural, Burst lobe Neoplastic- Tumour with oedema Others- Epilepsy, Hydrocephalus Extracranial: Metabolic – Hypo/Hypernatraemia Hypo/Hyperkaleamia Hypo/Hypercalcaemia Hypo/Hyperglycaemia Hypo/Hyperthermia Diabetic ketoacidosis Lactic acidosis Uraemia Hepatic failure Hypercapnia Hypoxia
- 5. Causes of unconsciousness ( contd.) Arterial occlusion Vertebral artery disease Bilateral carotid disease Drugs: Sedatives, Opiates, Antidepressants, Anticonvulsants. Toxins: Alcohol, CO, Heavy metals Vascular cause: SAH, Intracerebral haematoma, Brain stem infarction and haemorrhage Infective cause: Meningitis Abscess Encephalitis Endocrine cause: Hypopituitarism Adrenal crisis Hypo/Hyper parathyroidism Hypothyroidism
- 6. Causes of unconsciousness ( contd.) Decrease cardiac output: Vasovagal attack Blood loss Valvular disease MI, Cardiac arrythmia, Hypotensive drug Psychiatric disorders: Hysteria Catatonia
- 7. Assessment of unconscious pt. • Initial assessment of the patient by GCS. • Max score: 15 • Min score: 3
- 8. Glasgow Coma Scale Eye –opening ( E) Spontaneous 4 To speech 3 To pain 2 Nil 1 Best Motor response (M) Obeys 6 Localises 5 Withdraws 4 Abnormal reflection 3 Extensor response 2 Nil 1 Verbal response (V) Orientated 5 Confused Conversation 4 Inappropriate words 3 Incomprehensible sounds 2 Nil 1
- 9. Approach to the patient • Diagnostic approach: History Possible cause of coma/ Impaired conscious level Head injury leading to hospital admission Diffuse shearing injury and or intracranial haematoma Previous head injury (e.g. 6 weeks) Chronic subdural haematoma Sudden collapse Intracerebral haemorrhage Subarachnoid haemorrhage Limb twitching ,incontinence Epilepsy/post ictal state Gradual development of symptoms Mass lesion, metabolic or infective cause
- 10. Approach to a patient ( contd) History Possible cause of coma/ Impaired conscious level Previous illness Diabetes Hypo/(Less likely)Hyperglycaemia Epilepsy Postictal state Psychiatric illness Drug overdose Alcoholism or drug abuse Drug toxicity Viral infection Encephalitis Malignancy Intracranial metastasis
- 11. Examination of the patient • General Examination Note the presence of Possible cause of coma/ Impaired conscious level Laceration, bruising, CSF leak Head injury Internal auditory meatus Bleeding Head injury Pus Cerebral abscess/ Meningitis Enlarged head and Tense anterior frontanelle in infants Raised ICP Neck stiffness and retraction Tonsillar herniation Meningitis Positive Kernig’s sign Meningitis Tongue biting Epilepsy/Post ictal state
- 12. Examination of the patient • General Examination Note the presence of Possible cause of coma/ Impaired conscious level Emaciation, Hepatomegaly, lymphadenopathy Intracranial metastasis Infection source ( ear, sinus, lungs, valvular disease) Cerebral abscess, meningitis Pyrexia Cerebral abscess, meningitis Subarachnoid, intracerebra, pontine haemorrhage Hypotension /blood loss Reduced cardiac output Smell of alcohol Alcohol abuse Needle marks on limbs Drug abuse Snout rash Solvent abuse
- 13. Examination of the patient • Systemic examination: Note the presence of Possible cause of coma/ Impaired conscious level Cardiovascular Valvular heart disease Emboli Cardiac arrythmia Reduced cardiac output Respiratory Respiratory insufficiency Anoxia Neurological Signs of raised ICP Intracranial mass lesion Hydrocephalus Neurological signs Unilateral dilated fixed pupil Intracranial mass lesion, Hydrocephalus Bilateral dilated fixed pupil Intracranial mass lesion Diffuse cerebral swelling- anoxia Drugs- Anticholenergic and Sympathomimetics overdose
- 14. Examination of the patient • Systemic examination: Note the presence of Possible cause of coma/ Impaired conscious level Neurological ( contd) Pin point pupil Drugs- Opiates, parasympthomimetic, pontine haemorrhage Asymmetric limb response ( hemi or mono paresis) Focal brain damage- Tumour, trauma, haematoma, encephalitis Symmetrical limb responses , reacting pupils and full eye movements Metabolic encephalopathy or drug toxicity. Occasionally these may produce asymmetrical limb responses Subhyaloid or vitreous haemorrhage on fundoscopy SAH
- 15. Investigation The sequence of investigations depends on clinical suspicion Trauma Signs of raised ICP or focal neurological signs Urgent CT Scan Meningism If negative Do LP and CSF Study Suspected drug abuse or metabolic disease METABOLIC (If –ve) No signs of raised ICP SCREEN No meningism urea and electrolytes S. Ca No focal neurological signs Blood glucose S. PO4 ABG If not S.Mg Drug screen LFT diagnostic S.Folic A Blood culture S. Cortisol ( if pyrexia) Thyroid Ab
- 16. Investigation • In addition: • Skull X-ray : May reveal an unsuspected fracture, pineal shift, calcification or an osteolytic lesion. • Chest X-ray P/A: May reveal a bronchial carcinoma • EEG: Subclinical epilepsy • Herpes simplex encephalitis • Metabolic encepalopathy • MRI
- 17. Treatment • Supportive: 1. ABC. 2. Nutritional . 3. Care of Eye, Mouth, Bowel and Bladder. 4. Prevention of bed sore. Specific: According to the cause.
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