Approach to Unconscious Patients Wakefulness depends on the integrity of both cerebral hemi- spheres and the ascending reticular

activating formation of the brain stem. 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 History i) Onset of coma (abrupt, gradual) ii) Recent complaints ( headache, depression, focal weakness, vertigo ) iii) Recent injury iv) Previous medical illness (diabetes,uremia, heart disease) v) Access to drugs ( sedatives,psychotropic drugs ) Examination 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) Neurological Examination 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. Respiratory pattern a. Hyperventilation - midbrain and upper pons lesion metabolic diseases e.g. hepatic coma, diabetes and generalised increase in intracranial pressure in its early stages. b. Hypoventilation - medullary, upper cervical spinal lesion, drug overdose, and later stages of cerebral herniation. c. 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. 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. 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. 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. Decorticate Laboratory Evaluation Supratentorial lesions Skull radiograph Computerised tomographic scan CTscan) Carotid angiography EEG ( electroencephalogram ) Infratentorial lesions Skull radiograph CT scan Vertebral angiography EEG Ventriculography 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 Management Initial Management Airway Breathing Circulation Deformity Exposure Definitive Management In general, management of the comatose patient depends on the cause. However, while thepatient 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 Examination Vital Signs 1.Pulse tachycardia Hypovolemia/hemorrhage hyperthermia Intoxication bradycardia Raised intracranial pressure Heart blocks

2.Temperature Increased Sepsis Meningitis ,encephalitis Malaria ,Pontine haemorrhage Decreased Hypoglycemia Hypothermia (less than 31 C) Myxedema Alcohol, barbiturate ,sedative or phenothiazine intoxication. 3.Blood pressure increased Hypertensive encephalopathy Cerebral hemorrhage Raised intracranial pressure Decreased Hypovolemia /hemorrhage Myocardial infarction Intoxication/poisoning Profound hypothyroidism, Addisonian crisis 4.Respiratory rate Increased(tachypnea) Pneumonia Acidosis (DKA, renal failure) Pulmonary embolism Respiratory failure Decreased Intoxication/poisoning Skin petechial rash Meningococcal meningitis Endocarditis Sepsis, thrombotic thrombocytopenic purpura Rickettsial infection RMS (rocky mountain spotted fever) Multiple injection marks Drug addiction Acute endocarditis Hepatitis B/C with encephalopathy HIV Neurological assessment; General posture Level of conciousness Posture Lack of movements on one side Intermittent twitching Multifocal myoclonus DECORTICATION DECEREBRATION Level of conciousness 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 An abbreviated coma scale is used in the assessment of critically ill patient (primary survey) AVPU A alert V respond to voice stimulus P respond to pain U - unresponsive Brainstem reflexes Pupillary responses to light Spontaneous and elicited eye movements Corneal responses Respiratory movements Ocular Movements Conjugate deviation of eyes to a side ipsilateral hemisphere frontal lesion or contralateral pontine lesion. Rarely eyes may turn paradoxically away from the side of deep hemisphere lesion (WRONG-WAY EYES) Downward conjugate deviation of eyes mesencephalic lesion. Oculocephalic reflex (Dolls eyes response) brisk in cortical depression, lost in brainstem lesion. Oculovestibulo responses two components 1.Conjugate ocular movement lost in brainstem damage. 2.Nystagmus loss in damage to cerebral hemisphere Pupillary Changes Respiratory movements Has less localizing value than 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 (Kussmauls) in metabolic acidosis and in pontomesencephalic lesion. Neck rigidity; Meningitis Subarachnoid hemorrhage Fundoscopy Raised intracranial pressure Hypertensive changes Subarachnoid hemorrhage Diabetic retinopathy History Onset of the symptoms Antecedent symptoms Use of medications Chronic liver, kidney, lung or heart disease CAUSES OF UNCONCIOUSNESS Causes of unconsciousness Metabolic Drugs, poisoning e.g. alcohol Hypoglycemia, hyperglycemia (keto acidotic state) Hypoxia (COPD) Septicemia Hypothermia Myxedema ,addisonian crisis Hepatic/uremic encephalopathies Neurological Trauma Infections meningitis, encephalitis, malaria, typhoid, rabies. Tumors cerebral/meningeal tumors

Vascular subdural / subarachnoid hemorrhage, stroke, hypertensive encephalopathy Epilepsy nonconvulsive status Summary ABC of life support Oxygen and I.V access Stabilize cervical spine Blood glucose Control seizures Consider I.V glucose, thiamine, naloxone, flumazenil Brief examination and obtain history Investigate Reassess the situation and plan further Discharge Plan/Health Teaching Early management Prompt diagnosis Increased ICP Normal range: 5 13 mmHg Collaborative Management for Clients with Increased ICP Semi-fowlers position, lateral position Adequate oxygenation Safety Rest Avoid factors that increased ICP such as nausea and vomiting, valsalva maneuver, oversuctioning, restraints application, rectal examination, enema, and bending or stooping Continuation Control hypertension Restrict fluid intake Pharmacotherapy Pharmacotherapy Mannitol Lasix (furosemide) Decadron (dexamethasone) Anticonvulsants (Diazepam, Dilantin,Phenobarbital, Tegretol) Antacids Histamine- H2 blocker antagonist anticoagulants Care of the Client with Altered Levels of Consciousness Maintain stimulation Maintain nutrition Maintain elimination Maintain circulation Maintain normal body temperature Promote safety Promote activity Maintain skin integrity Maintain good hygiene Support family