Transcript Management of unconscious patient

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
a. Hypoxia
b. Ischemia
c. Hypoglycemia
• Alteration of neurophysiologic responses of neuronal
membranes
a. Drug intoxication
b. Alcohol intoxication
c. Epilepsy
Common Causes II
• Abnormalities of osmolarity
a. Diabetic ketoacidosis
b. Nonketotic hyperosmolar state
c. 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
• Rate
• Rhytme
• Arterial Pressure
• 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
•II. Verbal Response
6 - Obeys commands fully
5 - Alert and Oriented
5 - Localizes to noxious stimuli
4 - Confused, yet coherent, speech
4 - Withdraws from noxious stimuli
3 - Inappropriate words and jumbled
3 - Abnormal flexion, i.e. decorticate
phrases consisting of words
posturing
2 - Incomprehensible sounds
2 - Extensor response, i.e.
1 - No sounds
decerebrate posturing
•III. Eye Opening
1 - No response
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
History of diabetes, use of oral
Diagnosis
* Hypoglycaemia
Action
• *Test blood for glucose using
anti-diabetic or ingestion of
test strip or glucose meter.
alcohol
• Give IV Glucose
History of ingestion of
Drug overdose.
• Support respiration
medication (tablets or liquid).
e.g. Alcohol,
• IV Glucose to prevent
There may be smell of alcohol
hypoglycaemia.
or other substance on breath
In chronic alcoholics
• Precede IV glucose with IV
Thiamine, IV fluid
administration.
E.g. Paracetamol.
• Gastric lavage, nacetylcysteine treatment if >
140 mg/kg body weight
ingested
Complaints
Diagnosis
Action
Presence or absence of history * Diabetic ketoacidosis
• *Give Soluble Insulin and
of diabetes;
Sodium Chloride 0.9% infusion
- polyuria, polydipsia
- hyperventilation
- gradual onset of illness
- evidence of infection
- Urine sugar and ketone
positive
- Blood glucose> 250 mg/dL
Fever, fits, headache, neck
* Meningitis or Cerebral Malaria • *Treat with antibiotics and
stiffness, altered
quinine until either diagnosis
consciousness etc
confirmed.
History of previous fits, sudden * Epilepsy
• *Give Diazepam, IV, to abort
onset of convulsions; with or
fits and continue or start with
without incontinence.
anti-epileptic drug treatment
Complaints
Patient with hypertension or
diabetes; sudden onset of
Diagnosis
* Stroke
Action
• Check blood pressure and
blood glucose.
paralysis of one side of body.
Patient with hypertension,
headaches, seizures
* Hypertensive encephalopathy • Check blood pressure
• If very high, give oral or
parenteral anti-hypertensives
Thank you for your attention