Presentation by dr. mottalib

Management of Unconscious patient Prepared by- Dr. Abdul Mottalib Sarker

Definition Persistent loss of consciousness or coma indicates disorder of the arousal mechanism in the brain stem & diencephalon, and indicates bilateral hemisphere or brain stem disease.

Causes of coma Metabolic disturbance - Drug overdose -Diabetes mellitus (Hypoglycemia. Kitoacidosis, Hyperosmolar coma) -Hyponatremia -Uremia -Hepatic failure -Respiratory failure -Hypothermia -Hypothyroidism

Trauma - Cerebral Contusion -Extradural hematoma -Subdural hematoma

Cerebrovascular disease - Subarachnoid hemorrhage -Intracerebral hemorrhage -Brain stem infarction/hemorrhage -Cerebral venous sinus thrombosis

Infections - Meningitis -Encephalitis -Cerebral abscess -General sepsis -Cerebral malaria Other - Epilepsy -Thiamin deficiency -Brain tumor

Quick history Abrupt/gradual onset Any suicidal note/seizure If injured, suspect cervical spine injury & do not move spine Recent complication- headache, fever, vertigo, depression

Recent medical history- -sinusitis -otitis media -neurosurgery -ENT procedure Drug/toxin exposure Any traveling history

Past medical history- -Diabetes, -Asthma, -Blood pressure, -Cancer, -Epilepsy, -Psychiatric illness

Plan of immediate management ABC of life support IV access Stabilize the cervical spine (if trauma) Blood glucose Control seizure Treat potential causes. eg. iv glucose, thiamine, naloxane (if pupils small or if possible narcotic use), other antidot

Immediate management D anger – Looking for Dangers (any focal neurological deficit) R esponse – Checking Response . Use the Glasgow Coma Scale to ascertain level of consciousness A irway – Examining the Airway for obstruction and Cervical Spine Control in the event of any possible trauma B reathing – Look, Listen and Feel for adequate respiratory effort. Supplement with O2 to correct hypoxia if saturations are below 95%.

C irculation – Checking the Circulation. If a carotid pulse is not palpable then resuscitation should be commenced Check the blood glucose Give 50 ml 50% dextrose IV stat if hypoglycemia possible

IV thiamine if any suggestion of Wernicke’s encephalopathy IV naloxane (0.4-2 gm iv) for optic intoxication (may also given IM or via ET tube )

Glasgow Coma scale The scale comprises three tests: eye , verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death ), while the highest is 15 (fully awake person). Obeys command Localizes painful stimuli Flexion / Withdrawal to painful stimuli Abnormal flexion to painful stimuli Extension to painful stimuli Makes no movements Motor N/A Oriented, converses normally Confused, disoriented Utters inappropriate words Incomprehensible sounds Makes no sounds Verbal N/A N/A Opens eyes spontaneously Opens eyes in response to voice Opens eyes in response to painful stimuli Does not open eyes EYE 6 5 4 3 2 1

Examination Neurological Examination Level of consciousness - by Glasgow Coma scale, which was described earlier. Respiratory pattern – - Cheyne-stoke breathing -Hyperventilation -Ataxic -Apneustic ( breath-holding pattern, which is brainstem damage with grave prognosis )

Eye - Pupil Visual field Extra ocular movement Fundi for – papilloedema hypertensive retinopathy diabetic retinopathy

Examine for CNS asymmetry – -tone -spontaneous movement -reflexes

Other examination Signs of trauma – -haematoma -bruish -laceration -CSF/blood in nose/ear -fracture ‘step’ deformity of skull -subcutaneous emphysema

Stigmata of other illness- -liver disease -alcoholism -diabetes -myxoedema

Skin for - - needle marks -cyanosis -pallor -rash (meningitis, typhus)

Smell the breath -alcohol -hepatic fetor -ketosis -uremia

Heart examination for -Blood Pressure -Murmur -rubs Lung examination for -wheeze -consolidation -collapse

Opisthotonus – meningitis or tetanus

Abdominal for -organomegally -ascitis -bruising -peritonitis -melaena If there is any foci of infection- - abscess -bites -middle ear infection

Any feature of meningitis – - Neck rigidity - kernig’s sign -Brudzinski’s sign

Pupil Both pupils are dilated and unreactive to light. This could be due to overdose of certain medications, hypothermia or severe anoxia (lack of oxygen). • ʖ • One pupil is dilated and unreactive, while the other is normal (in this case the L eye is dilated but the R eye is normal in size). This could mean a damage to the oculomotor nerve (cranial nerve number 3, CN III) on the right side, or possibility of vascular involvement. • ʖ• "Pinpoint" pupils indicate heroin or opiate overdose, and can be responsible for a patient's coma. The pinpoint pupils are still reactive to light, bilaterally (in both eyes, not just one). Another possibility is the damage of the pons. • ʖ • Normal eye with two pupils equal in size and reactive to light. This means that the patient is probably not in a coma and is probably lethargic, under influence of a drug, or sleeping. • ʖ • Possible interpretation Pupil sizes (Left eye vs. Right eye)

Investigation Full Blood Count Urine R/E Liver Function Test ESR Arterial Blood Gas analysis CRP

Ethanol Toxic screen Drug levels Blood culture Urine culture

Consider malaria Chest X-ray CT scan of brain

Treatment Treatment of unconscious patient is according to cause, such as- If Hypoglycemic coma- I/V infusion of 20-30ml 50% glucose over a period of 2-3 min or Glucagon 1mg I/M injection

If Diabetic keto-acidosis- short acting insulin fluid replacement Potassium replacement Antibiotic if necessary If stroke – Antibiotic , Dexamethasone etc. Other causes treated accordingly.

Presentation by dr. mottalib

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