1. Management of unconscious patient
Özlem Korkmaz Dilmen
Associate Professor of Anesthesiology and Intensive Care
Cerrahpasa School of Medicine

2. Learning Objectives Definition of unconsciousness Common causes
Diagnosis and treatment of unconscious patient

3. 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.

4. A system of upper brainstem and thalamic neurons, the reticular activating system and its broad connections to the cerebral hemispheres maintain wakefulness.

6. Common Causes I Interruption of energy substrate delivery Hypoxia
Ischemia
Hypoglycemia
Alteration of neurophysiologic responses of neuronal membranes
Drug intoxication
Alcohol intoxication
Epilepsy

7. Common Causes II Abnormalities of osmolarity Diabetic ketoacidosis
Nonketotic hyperosmolar state
Hyponatremia
Hepatic encephalopathy
Hypertensive encephalopathy
Uremic encephalopathy

8. Common Causes III
Hypercapnia
Hypothyroidism
Hypothermia
Hyperthermia

9. An unconscious case
46 years old, male DM
Unconscious

11. First Aid A (Airway) B (Breathing) C (Circulation) D (Disability)
E (Exposure)

12. Airway - A
Head tilt, chin lift
Jaw trust

13. Airway - A
Clearance (aspiration)
Oral/Nasal Airway
Intubation

14. Breathing - B
Look, listen and feel for NORMAL breathing.

15. Breathing - B
Symmetry
Breathing Sounds
Tidal Volume
Respiratory rate

16. 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

17. Circulation - C Pulse Arterial Pressure Rate Rhytme Hypertension
Hypotension

18. 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

19. GLASGOW COMA SCALE
I. Motor Response 6 - Obeys commands fully 5 - Localizes to noxious stimuli 4 - Withdraws from noxious stimuli 3 - Abnormal flexion, i.e. decorticate posturing 2 - Extensor response, i.e. decerebrate posturing 1 - No response
II. Verbal Response Alert and Oriented Confused, yet coherent, speech Inappropriate words and jumbled phrases consisting of words Incomprehensible sounds No sounds
III. Eye Opening Spontaneous eye opening Eyes open to speech Eyes open to pain No eye opening

20. Exposure an Environment - E
The patient’s clothes should be removed or cut in an appropriate manner so that any injuries can be seen.

21. General Physical Examination
History
Neurologic examination
The eye examination
Fundoscopy
Ventilatory pattern

22. History In many cases, the cause of coma is immediately evident;
Trauma
Cardiac arrest
Drug ingestion
In the reminder, historical information may be helpful. .

24. Cirrhosis

26. Meningococcemic rashs

28.  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. 

29. Neck rigidity

30. Neck rigidity
Bacterial meningitis
Subarachnoid hemorrhage

31. Hepatic coma

32. 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.

33. Fixed and dilated pupils

34. Fixed and dilated pupils
The terminal stage of brain death
Atropine effect

35. Pinpoint pupils

36. Pinpoint pupils
Narcotic overdose
Bilateral pontine damage

37. Pupillary dilatation

38. Pupillary dilatation
Sudden lesion of the midbrain; ruptere of an internal carotid artery aneurysm

39. Fundoscopic examination

40. Fundoscopic examination
Subarachnoid hemorrhages
Hypertensive ensefalopaty
Increased inrtacranial pressure

41. Laboratory examination
Chemical blood determinations are made routinely to investigate metabolic, toxic or drug induced encephalopaties.
Electrolytes
Calcium
Blood urea nitrogen
Glucose
NH3

42. 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.

43. Imaging In coma of unknown etiology, CT or MRI must be performed.
Radiologically detectable causes of coma;
Hemorrhage
Tumor
Hydrocephalus

44. Brain herniation

46. Electroencephalography
EEG is useful in unrecognized seizures.

47. 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.

48. Complaints Diagnosis Action
History of diabetes, use of oral anti-diabetic or ingestion of alcohol
* Hypoglycaemia
• *Test blood for glucose using test strip or glucose meter. • Give IV Glucose
History of ingestion of medication (tablets or liquid). There may be smell of alcohol or other substance on breath
Drug overdose. e.g. Alcohol,
• Support respiration • IV Glucose to prevent hypoglycaemia. In chronic alcoholics • Precede IV glucose with IV Thiamine, IV fluid administration.
E.g. Paracetamol.
• Gastric lavage, n- acetylcysteine treatment if > 140 mg/kg body weight ingested

49. Complaints Diagnosis Action
Presence or absence of history of diabetes; - polyuria, polydipsia - hyperventilation - gradual onset of illness - evidence of infection - Urine sugar and ketone positive - Blood glucose> 250 mg/dL
* Diabetic ketoacidosis
• *Give Soluble Insulin and Sodium Chloride 0.9% infusion
Fever, fits, headache, neck stiffness, altered consciousness etc
* Meningitis or Cerebral Malaria
• *Treat with antibiotics and quinine until either diagnosis confirmed.
History of previous fits, sudden onset of convulsions; with or without incontinence.
* Epilepsy
• *Give Diazepam, IV, to abort fits and continue or start with anti-epileptic drug treatment

50. Complaints Diagnosis Action
Patient with hypertension or diabetes; sudden onset of paralysis of one side of body.
* Stroke
• Check blood pressure and blood glucose.
Patient with hypertension, headaches, seizures
* Hypertensive encephalopathy
• Check blood pressure • If very high, give oral or parenteral anti-hypertensives

51. Thank you for your attention