Management of unconscious patient

1. Management of unconscious patient Özlem KorkmazDilmen Associate Professor of Anesthesiology and Intensive Care Cerrahpasa School of Medicine

2. Learning Objectives • Definition of unconsciousness • Common causes • Diagnosis and treatment of unconscious patient

3. 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.

4. A system of upper brainstem and thalamic neurons, the reticular activating system and its broad connections to the cerebral hemispheres maintain wakefulness.

6. Common Causes I • Interruption of energy substrate delivery • Hypoxia • Ischemia • Hypoglycemia • Alteration of neurophysiologic responses of neuronal membranes • Drug intoxication • Alcohol intoxication • Epilepsy

7. Common Causes II • Abnormalities of osmolarity • Diabetic ketoacidosis • Nonketotichyperosmolar state • Hyponatremia • Hepatic encephalopathy • Hypertensive encephalopathy • Uremic encephalopathy

8. Common Causes III • Hypercapnia • Hypothyroidism • Hypothermia • Hyperthermia

9. Anunconscious case • 46 years old, male • DM • Unconscious

11. First Aid • A (Airway) • B (Breathing) • C (Circulation) • D (Disability) • E (Exposure)

12. Airway - A • Head tilt, chin lift • Jaw trust

13. Airway - A • Clearance (aspiration) • Oral/Nasal Airway • Intubation

14. Breathing - B • Look, listen and feel for NORMAL breathing.

15. Breathing - B • Symmetry • Breathing Sounds • Tidal Volume • Respiratory rate

16. 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

17. Circulation - C • Pulse • Rate • Rhytme • Arterial Pressure • Hypertension • Hypotension

18. 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

19. 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

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

21. General Physical Examination • History • Neurologic examination • The eye examination • Fundoscopy • Ventilatory pattern

22. History • In many cases, the cause of coma is immediately evident; • Trauma • Cardiac arrest • Drug ingestion • In the reminder, historical information may be helpful. .

24. Cirrhosis

26. Meningococcemicrashs

28. 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.

29. Neck rigidity

30. Neck rigidity • Bacterial meningitis • Subarachnoid hemorrhage

31. Hepatic coma

32. 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.

33. Fixed and dilated pupils

34. Fixed and dilated pupils • The terminal stage of brain death • Atropine effect

35. Pinpoint pupils

36. Pinpoint pupils • Narcotic overdose • Bilateral pontine damage

37. Pupillary dilatation

38. Pupillary dilatation Sudden lesion of the midbrain; ruptere of an internal carotid artery aneurysm

39. Fundoscopic examination

40. Fundoscopic examination • Subarachnoid hemorrhages • Hypertensive ensefalopaty • Increased inrtacranial pressure

41. Laboratory examination Chemical blood determinations are made routinely to investigate metabolic, toxic or drug induced encephalopaties. • Electrolytes • Calcium • Blood urea nitrogen • Glucose • NH3

42. 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.

43. Imaging • In coma of unknown etiology, CT or MRI must be performed. • Radiologically detectable causes of coma; • Hemorrhage • Tumor • Hydrocephalus

44. Brain herniation

46. Electroencephalography EEG is useful inunrecognized seizures.

47. 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.