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
2 - Incomprehensible sounds
3 - Abnormal flexion, i.e.
1 - No sounds
decorticate posturing
III. Eye Opening
2 - Extensor response, i.e.
4 - Spontaneous eye opening
decerebrate posturing
3 - Eyes open to speech
1 - No response
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
anti-diabetic or ingestion of
alcohol
History of ingestion of
medication (tablets or liquid).
There may be smell of alcohol
or other substance on breath
Diagnosis Action
* Hypoglycaemia *Test blood for glucose using
test strip or glucose meter.
Give IV Glucose
Drug overdose. Support respiration
e.g. Alcohol, 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
 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 Diagnosis Action

Patient with hypertension or * Stroke Check blood pressure and

diabetes; sudden onset of blood glucose.
paralysis of one side of body.

Patient with hypertension, * Hypertensive encephalopathy Check blood pressure

headaches, seizures If very high, give oral or
parenteral anti-hypertensives
Thank you for your attention