APPROACH TO THE UNRESPONSIVE PATIENT

1. APPROACH TO THE UNRESPONSIVE PATIENT GREGORY MICK D.O.,F.A.C.O.S CENTRAL WASHINGTON NEUROSCIENCE CLINIC and Don Hudson, D.O., FACEP/ACOEP

2. INITIAL CONSIDERATIONS • THE UNRESPONSIVE PATIENT, ESPECIALLY WITH A HISTORY OF TRAUMA, PRESENTS US WITH A STRESSFUL AND CHALLENGING SITUATION • THERE ARE FEW SURVIVABLE COMPLICATIONS OF HEAD INJURY THAT WILL KILL YOUR PATIENT IN THE FIRST FEW HOURS. • MANY OTHER PROBLEMS CAN, SUCH AS : CARDIAC TAMPONADE, PNEUMOTHORAX, LACERATIONS OF MAJOR ABDOMINAL ORGANS, FRACTURES- ESPECIALLY PELVIC FRACTURES

3. INITIAL CONSIDERATIONS cont. • APPROPRIATE TRIAGE INCLUDES ABC’s • SECONDARY BRAIN INJURY • PREVENTABLE SEQUELAE OF INADEQUATE • OXYGENATION • HYPOTENSION ALMOST ALWAYS IS DUE TO INJURY OTHER THAN HEAD INJURY • CUSHING PHENOMENON • INCREASE IN ICP RESULTS IN DECREASED HR DECREASED RESPIRATIONS • MUST ALWAYS ASSUME CERVICAL INJURY PRESENT

4. BASIC NEUROANATOMY • RETICULAR ACTIVATING SYSTEM • FIBERS ORIGINATING IN BRAINSTEM ,SPREADING UPWARD INTO THE CEREBRAL HEMISPHERES • RESEMBLES A BOUQUET OF FLOWERS • STRUCTURE MOST RESPONSIBLE FOR CONSCIOUSNESS • GLOBAL vs. LOCALIZED INSULT • DUE TO THE ANATOMICAL DESIGN OF RAS, LESIONS MUST AFFECT ALL OF THE FIBERS IN ORDER TO CAUSE COMA

5. BASIC NEUROANATOMY cont. • TOXIC ENCEPHALOPATHY • DRUG OVERDOSE • DRUG REACTIONS • ENVIRONMENTAL EXPOSURES • METABOLIC ENCEPHALOPATHY • DIABETES • HEPATIC FAILURE • SEPSIS • MENINGITIS • BRAIN METABOLISM • BRAIN UTILIZES ONLY GLUCOSE ,GLUCONEOGENESIS OF • NO USE

6. BEDSIDE CLINICAL EVALUATION • GROSS OBSERVATION • WATCH PATIENT RESPONSE TO INTUBATION (gag) • WATCH EXTREMITIES FOR MOVEMENT(IV START) • PALPATE SCALP • OBSERVE FOR ECHYMOSIS (BATTLE’S SIGN,RACOON EYES) FACIAL ASYMMETRY(CRANIAL NEUROPATHY) • EPISTAXIS • HEMOTYMPANUM

7. BEDSIDE CLINICAL EVAL cont. • LEVEL OF CONSCIOUSNESS VERBALIZATION ORIENTATION • APHASIA FLUENTvsNON-FLUENT • PAIN RESPONSE LOCALIZED vs. GENERALIZED WITHDRAWAL POSTURING RESPONSE(FLEXIONvs EXTENSION • EYE MOVEMENT DOLL’S EYE (INDICATES MID-BRAIN FUNCTION) CALORIC TESTING

8. BEDSIDE CLINICAL EVAL cont. • PUPILLARY SIZE & REACTION • CORNEAL REFLEX( CN V) • GAG REFLEX ( CNIX & CNXII) • MUSCLE STRENGTH & TONE • DEEP TENDON REFLEXES • BABINSKI & HOFFMAN SIGNS

9. GLASCOW COMA SCALE • Pts BEST EYE BEST VERBAL MOTOR • 6 - - OBEYS • 5 - ORIENTED LOCALIZES • 4 SPONTANEOUS CONFUSED WITHDRAWS • 3 TO SPEECH INAPPROPRIATE FLEXOR • 2 TO PAIN INCOMPREHENSIBLE EXTENSOR • 1 NONE NONE NONE

10. Lab and X-ray • LABORATORY EVALUATION • CBC, CHEM PROFILE, ABG, URINE & SERUM TOXICOLOGY, UA, ECG, CXR, APPROPRIATE C&S • RADIOLOGY EVALUATION • C-SPINE X-RAY • CT OF HEAD • CT OF QUESTIONALE SPINE X-RAYS

11. Therapeutic Interventions • MAINTAIN C-COLLAR UNTIL C-SPINE CLEARED BY PHYSICIAN • ESTABLISH AIRWAY ETT vs. TRACHEOSTOMY • ARTIFICIAL RESPIRATION (MAINTAIN NORMAL pCO2) • MAINTAIN ADEQUATE BP • CONTROL ICP/CPP • CPP=MAP-ICP • NALOXONE • MANNITOL/FUROSEMIDE • NIMODIPINE • CORTICOSTEROIDS ???? • SZ PREVENTION • GLUCOSE

12. Your Worries • Pre-hospital care can be a challenge • Always assume the worse, c-spine Fx, blood loss, cardiac event, suicide gesture, metabolic problems or intra-cranial event