Approach to

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Approach to
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Contents

• Clinical Evaluation
• History
• Examination
• Lab Evaluation
• Management

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Basics

• Wakefulness depends on the integrity of
  both cerebral hemi- spheres and the ascending
  reticular activating formation of the brain stem.
  

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Cont..

• 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

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• History

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• Onset of coma
• (abrupt,
  gradual)
• ii) Recent complaints
• ( headache, depression, focal
  weakness, vertigo )
• iii) Recent injury
• iv) Previous medical illness
• ( diabetes,uraemia, heart disease )
• v) Access to drugs
• ( sedatives,psychotropic drugs )

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• Examination

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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)

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• Neurological Examination

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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.

Stupor the subject can be roused
only by vigorous and repeated
noxious stimuli.
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Respiratory pattern

• a ) Hyperventilation - midbrain and upper pons
  lesion
• metabolic diseases e.g. hepatic coma, diabetes
  and generalised raised intracranial pressure in
  its early stages.
• ( b ) Hypoventilation - medullary, upper cervical
  spinal lesion
• Drug overdose and later stages of
  cerebral herniation.
• ( e ) 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

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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.

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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 12 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.

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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.

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• Laboratory Evaluation

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Supratentorial lesions

• Skull radiograph
• Computerised tomographic scan CTscan)
• Carotid angiography
• EEG ( electroencephalogram )

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Infratentorial lesions

• Skull radiograph
• CT scan
• Vertebral angiography
• EEG
• Ventriculography

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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

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• Management

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Initial Management

• Airway
• Breathing
• Circulation
• Deformity
• Exposure

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Definitive Management

• In general, management of the comatose patient
  depends on the cause. However, while the patient
  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

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• You are in emergency department when an
  unconscious patient land in emergency with B.P
  90/50 pulse 92/min and attendants tell u that
  the patient suddenly fell unconscious, how will
  you approach ?

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APPROACH

• ABC
• Immediate management
• Examination
• History
• Investigations

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ABC
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Immediate management

• Maintain i.v line, oxygen inhalation
• Blood sample for RBS
• Control seizures
• Consider i.v glucose, thiamine, naloxone,
  flumazenil

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Examination
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CONTD.

• Vitals
• 1.Pulse
• tachycardia
• Hypovolemia/haemorrhage
• hyperthermia
• Intoxication
• bradycardia
• Raised intracranial pressure
• Heart blocks

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CONTD.

• 2.Temperature increased
• Sepsis
• Meningitis ,encephalitis
• Malaria ,Pontine haemorrhage
• Decreased
• Hypoglycemia
• Hypothermia (less than 31 C)
• Myxedema
• Alcohol, barbiturate ,sedative or phenothiazine
  intoxication.

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CONTD.

• 3.Blood pressure
• increased
• Hypertensive encephalopathy
• Cerebral haemorrhage
• Raised intracranial pressure
• Decreased
• Hypovolemia /hgr
• Myocardial infarction
• Intoxication/poisoning
• Profound hypothyroidism, Addisonian crisis

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CONTD.

• 4.Respiratory rate
• Increased(tachypnae)
• Pneumonia
• Acidosis (DKA, renal failure)
• Pulmonary embolism
• Respiratory failure
• Decreased
• Intoxication/poisoning

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CONTD.

• Skin petechial rash
• Meningococcal meningitis
• Endocarditis
• Sepsis,thrombotic thrombocytopenic purpura
• Rickettsial infection
• RMS (rocky mountain spotted fever)

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CONTD.

• Multiple injection marks
• Drug addiction
• Acute endocarditis
• Hepatitis B /C with encephalopathy
• HIV

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CONTD.

• Neurological assessment
• General posture
• Level of conciousness

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CONTD.

• Posture
• Lack of movements on one side
• Intermittent twitching
• Multifocal myoclonus
• DECORTICATION
• DECEREBRATION

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CONTD.

• 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

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CONTD.

• An abbreviated coma scale is used in the
  assessment of critically ill patient (primary
  servey)
• AVPU
• A alert
• V respond to voice stimulus
• P respond to pain
• U - unresponsive

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Brainstem reflexes

• Pupillary responses to light
• Spontaneous and elicited eye movements
• Corneal responses
• Respiratory movements

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CONTD.Ocular movements

• Conjugate deviation of eyes to a side
  ipsilateral hemisphere frontal leison or
  contralateral pontine leison. Rarely eyes may
  turn paradoxically away from the side of deep
  hemisphere leison (WRONG-WAY EYES)
• Downward conjugate deviation of eyes
  mesencephalic leison.

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CONTD.

• Eyes turn down and inward in thalamic hgr and
  upper midbrain leison.
• Ocular bobbing is diagnostic of pontine hgr.
• Ocular dipping - indicates diffuse cortical
  anoxic damage.
• Dysconjugate ocular deviation brainstem leison.

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CONTD.

• Oculocephalic reflex (Dolls eyes response)
  brisk in cortical depression ,lost in brainstem
  leison.
• Oculovestibulo responses two components
• 1.Conjugate ocular movement loss in brainstem
  damage.
• 2.Nystagmus loss in damage to cerebral
  hemisphere

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CONTD.Pupillary changes
Sr no pupils causes
1 B/L Pin-point pupils ( less than 1mm)but responsive Opiates poisoning ,extensive pontine hgr.
2 B/L small pupils but responsive B/L diencephalon involvement or destructive pontine leison
3 B/L slightly small pupils(1 to 2.5 mm) but responsive Metabolic encephalopathies ,deep B/L hemisphere leison or thalamic hgr.
4 B/L dilated and fixed Severe midbrain damage, Overdose of atropine,scopolamine, glutethemide.
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CONTD.
Sr. no. Pupil cause
6 U/L small pupil Horner syndrome
5 Ipsilateral dilated pupil with no direct or consensual reflexes Compression of 3rd cranial nerve e.g, uncal herniation
7 U/L small and irregular pupil unresponsive Leison in pretectal area of midbrain
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CONTD.Respiratory movements

• Has less localizing value then 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 (Kussmaul) in metabolic
  acidosis and in pontomesencephalic leison.

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Neck rigidity

• Meningitis
• Subarachnoid haemorrhage

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Fundoscopy

• Raised intracranial pressure
• Hypertensive changes
• Subarachnoid haemorrhage
• Diabetic retinopathy

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History

• Onset of the symptoms
• Antecedent symptoms
• Use of medications
• Chronic liver ,kidney ,lung or heart disease

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CAUSES OF UNCONCIOUSNESS
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Causes of unconciousness

• Metabolic
• Drugs, poisoning e.g CO ,alcohol
• Hypoglcemia, hyperglycemia (keto acidoti or HONK)
• Hypoxia, carbondiaoxide narcosis (COPD)
• Septicemia
• Hypothermia
• Myxedema ,addisonian crisis
• Hepatic / uremic encephalopathy

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CONTD.

• Neurological
• Trauma
• Infections meningitis, encephalitis, malaria,
  typhoid, rabies, trypanosomiasis.
• Tumours cerebral / meningeal tumors
• Vascular subdural / subarachnoid hgr, stroke,
  hypertensive encephalopathy
• Epilepsy nonconvulsive status / postictal state

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Immediate investigations

• RBS
• Blood CP and ESR
• LFTs
• Urea and Creatnine
• Blood and urine cultures

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Other investigations

• CRP
• ABGs
• Toxic screen , drug levels
• Lumbar puncture and CXR
• CT scan

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Summary

• ABC of life support
• Oxygen and I.V access
• Stabilize cervical spine

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CONTD.

• Blood glucose
• Control seizures
• Consider I.V glucose, thiamine, naloxone,
  flumazenil

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CONTD.

• Brief examination and obtain history
• Investigate
• Reassess the situation and plan further

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Take home message

• Early management
• Prompt diagnosis

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MCQ

• Pupillary changes in opiate poisoning
• 1.B/L pinpoint
• 2.U/L pin point
• 3.B/L dilated

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Answer

• 1. B/L pin point

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MCQ

• Myxoedema coma seen in
• 1.Euthyroid state
• 2.Hyperthyroid state
• 3. hypothyroid state

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Answer

• 3. hypothyroid state

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THANK YOU
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• Thank You