Approach to Unconscious patient

You are in emergency department when an unconscious patient with BP : 90/50 mmHg Pulse : 92 bpm How will you approach ?

APPROACH
ABC Immediate management Examination History Investigations

Immediate management
Assessment of the patient's : Airway Breathing Circulation inspect the tongue for signs of biting supplemental O2 Take a set of vitals at least every 15 minutes

 Two large bore IV accessone IV for fluids and another for medications.

An oral airway: ensure potency facilitate suctioning

 A nasogastric tube- prevent aspiration

An indwelling urinary catheter : incontinence monitor intake and output

Examination

Vitals Skin petechial rash Injection marks

Neurological assessment Neck rigidity Fundoscopy Brainstem reflexes

Detailed medical examination

Examination

Vitals Skin petechial rash Injection marks

Neurological assessment Neck rigidity Fundoscopy Brainstem reflexes

Detailed medical examination

Pulse
Tachycardia Hypovolemia/haemorrhage Intoxication hyperthermia Bradycardia Raised intracranial pressure Heart blocks

Temperature
Increased Sepsis Meningitis ,encephalitis Malaria ,Pontine haemorrhage Decreased Alcohol,barbiturate or phenothiazine intoxication Hypoglycemia Myxedema

Blood pressure
Increased Hypertensive encephalopathy Cerebral haemorrhage Raised intracranial pressure Decreased Hypovolemia Myocardial infarction Intoxication/poisoning Profound hypothyroidism/hyperthyroidism, Addisonian crisis

Respiratory rate
Increased Pneumonia Acidosis (DKA, renal failure) Pulmonary embolism Respiratory failure Decreased Intoxication/poisoning Brain tumours/ increase ICP

Skin petechial rash

Meningococcal meningitis

 Rickettsial infection RMS (rocky mountain spotted fever)

 Endocarditis

Sepsis,thrombotic thrombocytopenic purpura

Multiple injection marks

Drug addiction Acute endocarditis Hepatitis B /C with encephalopathy HIV

Neurological assessment
General posture

Level of conciousness

Posture
Lack of movements on one side Intermittent twitching

Multifocal myoclonus
DECORTICATION DECEREBRATION

 A system for assessing the depth of unconsciousness AVPU A alert V respond to voice stimulus P respond to pain U - unresponsive

Level of conciousness

3 - severe ; =<8 - moderate ; 9- 12 - minor injury

Brainstem reflexes
Spontaneous and elicited eye movements Pupillary responses to light Corneal responses Respiratory movements

Ocular movements
Downward conjugate deviation of eyes Eyes turn down and inward in Dysconjugate ocular deviation Ocular bobbing Ocular dipping Oculovestibulo responses

 Dolls eyes response

Pupillary changes
Sr no 1 pupils B/L Pin-point pupils ( less than 1mm) but responsive B/L small pupils but responsive causes Opiates poisoning ,extensive pontine hemorrhage B/L diencephalon involvement or destructive pontine leison Metabolic encephalopathies ,deep B/L hemisphere lesion or thalamic hgr.

B/L slightly small pupils(1 to 2.5 mm) but responsive

B/L dilated and fixed

Severe midbrain damage, Overdose of atropine, scopolamine and cocaine

Sr. no.

Pupil

cause

U/L small pupil

Horner syndrome

Ipsilateral dilated pupil with no Compression of 3rd cranial direct or consensual reflexes nerve e.g, uncal herniation

U/L small and irregular pupil unresponsive

Leison in pretectal area of midbrain

Respiratory movements
Cheyne-stokes respiration Kussmaul breathing Irregular respiration with random deep & shallow breaths Prolonged inspiratory gasp with a pause at full inspiration

Neck rigidity
Meningitis

Subarachnoid haemorrhage

Fundoscopy
Raised intracranial pressure Hypertensive changes Subarachnoid haemorrhage

Diabetic retinopathy

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

Possible Causes
Alcohol Epilepsy Trauma Infection Psychiatric Stroke, syncope

Insulin
Overdose Uremia (and other metabolic causes)

Causes of unconsciousness
Focal signs
Trauma Intracranial bleed Cerebral contusion
Vascular SAH Stroke Space occupying lesion Tumour Abscess

Diffuse signs
Infection Metabolic/Endocrine
Hyper/hypoglycaemia Hypothyroidism Acid-base disturbance Hyper/hyponatraemia Hepatic encephalopathy addisonion crisis

Toxic
Alcohol Recreational drugs Overdose

Hypothermia /Hyperthermia

Immediate investigations
RBS ESR LFTs Urea and Creatnine Blood and urine cultures

Other investigations
CRP ABGs Urine Ketone Toxic screen , drug levels

Lumbar puncture and CXR

CT scan

Management depends on the cause