Management of

unconscious patient
zlem 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

phrases consisting of words

3 - Abnormal flexion, i.e.

decorticate posturing
2 - Extensor response, i.e.
decerebrate posturing
1 - No response

2 - Incomprehensible sounds
1 - No sounds
III. Eye Opening
4 - Spontaneous eye opening
3 - Eyes open to speech
2 - Eyes open to pain
1 - No eye opening

Exposure an Environment - E
The patients 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