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Management of unconscious patient. Özlem 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.

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management of unconscious patient

Management of unconscious patient

Özlem KorkmazDilmen

Associate Professor of Anesthesiology and Intensive Care

Cerrahpasa School of Medicine

learning objectives
Learning Objectives
  • Definition of unconsciousness
  • Common causes
  • Diagnosis and treatment of unconscious patient
definition
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.

slide4
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
Common Causes I
  • Interruption of energy substrate delivery
  • Hypoxia
  • Ischemia
  • Hypoglycemia
  • Alteration of neurophysiologic responses of neuronal membranes
  • Drug intoxication
  • Alcohol intoxication
  • Epilepsy
common causes ii
Common Causes II
  • Abnormalities of osmolarity
  • Diabetic ketoacidosis
  • Nonketotichyperosmolar state
  • Hyponatremia
  • Hepatic encephalopathy
  • Hypertensive encephalopathy
  • Uremic encephalopathy
common causes iii
Common Causes III
  • Hypercapnia
  • Hypothyroidism
  • Hypothermia
  • Hyperthermia
an unconscious case
Anunconscious case
  • 46 years old, male
  • DM
  • Unconscious
first aid
First Aid
  • A (Airway)
  • B (Breathing)
  • C (Circulation)
  • D (Disability)
  • E (Exposure)
airway a
Airway - A
  • Head tilt, chin lift
  • Jaw trust
airway a1
Airway - A
  • Clearance (aspiration)
  • Oral/Nasal Airway
  • Intubation
breathing b
Breathing - B
  • Look, listen and feel for NORMAL breathing.
breathing b1
Breathing - B
  • Symmetry
  • Breathing Sounds
  • Tidal Volume
  • Respiratory rate
abnormal breathing
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
Circulation - C
  • Pulse
    • Rate
    • Rhytme
  • Arterial Pressure
    • Hypertension
    • Hypotension
disability d
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
GLASGOW COMA SCALE
  • I. Motor Response6 - 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 5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and jumbled phrases consisting of words 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
Exposure an Environment - E

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

general physical examination
General Physical Examination
  • History
  • Neurologic examination
  • The eye examination
  • Fundoscopy
  • Ventilatory pattern
history
History
  • In many cases, the cause of coma is immediately evident;
  • Trauma
  • Cardiac arrest
  • Drug ingestion
  • In the reminder, historical information may be helpful.

.

slide28

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 rigidity1
Neck rigidity
  • Bacterial meningitis
  • Subarachnoid hemorrhage
the eye examination
The eye examination

Pupillary abnormality is one of the cardinalfeatures 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 pupils1
Fixed and dilated pupils
  • The terminal stage of brain death
  • Atropine effect
pinpoint pupils1
Pinpoint pupils
  • Narcotic overdose
  • Bilateral pontine damage
pupillary dilatation1
Pupillary dilatation

Sudden lesion of the midbrain; ruptere of an internal carotid artery aneurysm

fundoscopic examination1
Fundoscopic examination
  • Subarachnoid hemorrhages
  • Hypertensive ensefalopaty
  • Increased inrtacranial pressure
laboratory examination
Laboratory examination

Chemical blood determinations are made routinely to investigate metabolic, toxic or drug induced encephalopaties.

  • Electrolytes
  • Calcium
  • Blood urea nitrogen
  • Glucose
  • NH3
laboratory examination1
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
Imaging
  • In coma of unknown etiology, CT or MRI must be performed.
  • Radiologically detectable causes of coma;
  • Hemorrhage
  • Tumor
  • Hydrocephalus
electroencephalography
Electroencephalography

EEG is useful inunrecognized seizures.

lumbar puncture
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.