Approach to

Patients with
Reduced alertness

Dr Subhankar Chatterjee
Associate In-Charge of CCU
Calcutta Heart Clinic & Hospital

Continuum of states of alertness

1.
2.
3.
4.

Conscious Alert and cooperative

Drowsy
Reduced alertness with easy arousal
Stupor
Can be awakes by vigorous stimuli
Coma patient cannot be aroused

Please use specific terms when describing a patient

Anatomy of consciousness

The ascending RAS, from the lower

border of the pons to the ventromedial
thalamus
The cells of origin of this system occupy a
paramedian area in the brainstem

Physiology of consciousness

Cerebral neurons are fully dependant on

blood supply(CBF) and delivery of oxygen and
glucose.

CBF~55ml per 100gm/min

Oxygen consumption~3.5mL per 100gm/min

Glucose utilization is 5mg per100gm/min

Brain store of Glucose provide energy for

2min after blood flow is interrupted

Oxygen store last for 8-10 second after blood

flow cessation

Principle causes of coma

1. Cerebral mass lesions

Principle causes of coma

2. Metabolic disorders
A. Interrupting delivery of energy substrate
Hypoxia

Hypoglycemia
Ischemia

B. Altering neuronal excitability

Drug overdose or unknown toxin

Alcohol intoxication
Anaesthesia
Epilepsy

C. Change in Ion Flux or neurotransmitter abnormality

Hyponatremia
Hypercalcemia
Change in osmolality
Hypercapnia
Hyperammonia

Metabolic causes of coma

D. Increased permeability of BBB to toxic substances

Uremia

E. Others
Hypothyroidism
Vit B12 deficiency
Hypothermia

In all metabolic disorders degree

of neurologic deficit co-relate
with Rapidity

Causes of coma cont..

5. Coma due to widespread
4. Toxic coma

( including

drug induced)

Very commonusually reversible

damage of cerebral
hemisphere

Hypoxic
encephalopathy
Cerebral malaria
TTP
Hyperviscocity
Diffuse axonal injury
following head trauma
Usually irreversible

Approaches to DD
Unresponsive
ABCs
Glucose, ABG, Lytes, Mg,
Ca, Tox, ammonia
IV D50, naloxone,
flumazenil

Brainstem N
or other
Focal signs
Y

CT

N
Unconscious

Pseudo-Coma
Psychogenic,
Looked-in,
NM
paralysis

Diffuse brain dysfunction

metabolic/ infectious
Focal lesions
Tumor, ICH/SAH/ infarction

LP
CT

Glasgow Coma Scale

Monitoring level of consciousness (score 3-15)

Eyes open
1.
Never
2.
To pain
3.
To verbal stimuli
4.
spontaneously
Best verbal response
1.
No response
2.
Incomprehensible sounds
3.
Inappropriate words
4.
Disoriented and converses
5.
Oriented and converses
Best motor response
1.
No response
2.
Extension (decerebrate rigidity)
3.
Abnormal flexion (decorticate rigidity)
4.
Flexion-withdrawal to pain
5.
Localizes pain
6.
Obeys commands

Immediate investigations

Blood Sugar
ABG
LFTs
Urea and Creatinine
Blood and urine cultures
CBC

Other investigations

CRP
Toxic screen , drug levels
Lumbar puncture
CXR
CT scan

History

Onset- sudden/gradual
Pre existing diseaseAssociated complain

Examination

Broad category of D/D

coma
With focal neurodeficit

Management
depends on the
cause

Case 1

70 yrs old male, known

hypertensive
presented in
emergency with
sudden onset LOC.
O/E- pulse 130/min,
BP-230/130, pupilconjugate deviation to
left, right hemiplegia,
E2M4V2

Next??

Manage ABCs
Is there any focal sign??

CT scan brain

Treatment:
ABC
Mannitol 1gm/kg loading
Urgent neurosurgical consultation

Case 2

75 yr/female presented in drowsy state,

relatives say she had repeated bouts of
vomiting in last 2 days.
O/E= pulse 110/min, temp-98,BP120/80, resp20/min, chest, NAD, no
rash
Next what to ask from history?

Next??

On asking family says she is diabetic,

took 30 unit Insulin daily but no food
yesterday.
So, What is the provisional diagnosis?
CBG 35mg%

Case3

78yr/male known hypertensive stays

single in a flat was discovered
comatose by his servant. He says,
patient was very lethargic since 2
days, even could not visit the family
doctor.
O/E= Vitals- stable, no neck rigidity,
no lateralising neurodeficit, no rash.
Next?

Case 3

CBG 130mg%, CT brain

Next??

TLC-12000, Na-120meq/L
Relatives found that patient took tab
Lasix 40mg BD for hypertension.

Case4

25yr female presented to ED in

unconscious state. She had a hot talk
with her husband few min ago before
she had LOC. She had locked jaw,
shivering of whole body.

Next ??

O/E- vitals- stable, No neurodeficit

CBG-100mg%,,
Na-135meq/L
EEG- normal
Ct Brain- NAD

Case 5

70/lady presented with gradually

increasing drowsiness over 1 week. No
h/o diuretic use, non diabetic
O/E-vitals stable, No focal neurodeficit,
no meningism, fundus- normal

Next??

CBG 130mg%
CT brainEEG- slow wave
Na- 135meq/L
TSH- 2.1
TLC-6700
CRP-4.0

Next??

On asking for drug history family says

she never took sedative, no diuretic but
he was on Vit D3 Injection for
Osteoporosis.
Serum Ca-14.0

Case 6

65/male presented with progressive

drowsiness with fluctuating symptom,
often he becomes aggressive.
Vitals- stable, No focal deficit, no
meningism.
Investigation- TLC-10,000, Na129meq/L, Ca-9.0, TSH-2.5, CBG135mg%,
Psychiatrist called.

NEXT ?

Case 7

70/female presented in a drowsy state.

She had a past h/o CVA 6 months back,
bed bound since the attack,
catheterized.
O/E- pulse-110/min, BP-110/70, Chestclear, No new neurodeficit, no
meningism, dehydrated.
No sedative drug, No Vit inj.

Next ??

CBG-120mg%
Na-143meq/L
Ca-8.4meq/L
CT brain
TSH-4.5

Next ??

Urine RE- pus cell plenty,

Patient was started IV antibiotic, Iv
fluid.
Urine C/S- E Coli

Case 8

20 yr/male, had RTA and presented

with LOC.
O/E- pulse-50/min, BP 160/100, lefthemiplegia, E2M3V2, temp 98

Next??

CT Brain Acute SDH

patient underwent urgent
neurosurgery

After 10 days following surgery

Patient had a vacant look, persistent

left weakness, afebrile.
CBG 120mg, Na-135meq/L, Ca-9.0,
CT brain- no blood clot
No sign of sepsis
Diffuse axonal injury

Case 9

75/male smoker presented with SOB 3

days, with acute onset drowsiness 6
hrs.
Pulse 120/min, BP-160/90, Chest- B/L
decreased air entry, No focal
neurodeficit, No meningism

Next ??

CBG 130mg
Na-135
CT brain- normal
Septic profile -normal
Next ??

Next ??

ABG- pH-7.20
Pco2- 100
PaO2-105
Hco3-30

Case 10

35yrs old diabetic lady

attended marriage
ceremony of a relative 3
days ago. Then she had
repeated vomiting,
presented in drowsy
state.
O/E- pulse120/min,
BP100/60, chest clear,
No meningism, no focal
deficit, grossly
dehydrated.

Next ??

CBG- Hi
Na-149meq/L
ABG- 7.30/38/70/18
Urine ketone ++

Case 11

65/male, known hypertensive, stopped

amlodipine 1 week back for no reason,
presented with acute onset drowsiness
for 6 hrs.
Pulse100/min, BP200/100,
papiledema+, No focal neurodeficit, No
meningism

Next ??

CBG 120mg%
Na- 135meq/L
Ca-8.5
TSH 2.3
MRI brain- No stroke/ hemorrhage

Next ??

BP was controlled gradually with Iv

Labetolol, amlodipine
Patient improved within 24 hrs

Case 12

65/female was brought from 60km

distance local hospital for drowsiness.
She was hypertensive, diabetic. Her
son says that she was rescued breaking
the door.
O/E- E2M5V2, pupil- Normal, No focal
deficit, No meningism,
BP 150/90, no papilledema

Next ??

CBG-150mg%
Ca-7
Na-130
CT brain-normal
What history may suggest the
diagnosis??

Next ??

Sedative overdose this patient after

48 hrs became awake and gave history
that she took 20 alprax tab after a hot
talk with her son.

Case 13

24/male presented with fever of 2

weeks followed by drowsiness. He had
2 episodes of convulsion at home.
O/E- pulse 130/min, BP-100/70, neck
rigitity+, pupil- mid dilated, no focal
deficit.

Next ??

CBG-120
Na-136
Ca-9

Next ??

CT brain

CSFcell count 1000( Neutrophil40%,

lymphocyte 55%)
sugar 80mg%
Tubercular meningitis

Case 14

70 yr lady, known hypertensive

presented with sudden LOC.
O/e- GTCS, E2M5V2, Left hemiparesis
BP-220/120,pulse 120, Irregular

CT Brain- on admission

Next?

CT was apparently normal, Patient was

managed with IV Mannitol, Phenytoin,
ET tube for securing airway.
CT repeated after 3 days

CT after 3 days:

Cardio-embolic stroke

Are you drowsy?