this slides explain the way to examine any unconsious patient in emergency medicine.

1. EXAMINATION
OF
UNCONSIOUS
PATIENT
- DR. KRUPAL MODI
- ASSISTANT PROFESSOR
- SSPTC
- KADODARA.

2.  In hospital neurology, the clinical analysis of
unresponsive and comatose patients
becomes a practical necessity. There is
always an urgency about such medical
problems.
 CAUSES FOR UNCONSIOUSNESS :
 “mass lesions,”—such as tumors, abscesses,
hemorrhages, and infarcts.
 exogenous (drug overdose) and endogenous
(metabolic) intoxications and hypoxia.
 Subarachnoid hemorrhage, meningitis, and
encephalitis etc….

3.  Normal Consciousness :
 This is the condition of the normal person
when awake.
 In this state the individual is fully
responsive to stimuli and indicates by his
behavior and speech the same awareness of
self and environment as that of the examiner.

4.  Unconsciousness has the opposite
meaning—
 A state of unawareness of self and
environment or a suspension of those mental
activities by which people are made aware of
themselves and their environment, coupled
with a diminished responsiveness to
environmental stimuli.

5.  level of consciousness—
 meaning the state of arousal or the degree of
variation from normal alertness as judged by
the appearance of facial muscles, fixity of
gaze, and body posture.

6. CAUSES for
unconsciousness
 Intracranial :
Trauma
Tumor with oedema
Subarachnoid hemorrhage
epilepsy, hydrocephalus, encephalitis
 Extracranial :
Diabetes
hypothyroidism
Lactic acidosis etc.

7.  Arterial occlusions
 Respiratory insufficiency
 Drugs
 toxins

8.  When the comatose patient is first seen, one must
quickly make sure that the patient's airway is clear and
the patient is not in shock.
 If trauma has occurred, one must check for bleeding
from a wound or ruptured organ (e.g., spleen or liver).
 If hypotension is present, certain therapeutic
measures—placement of a central venous line and
administration of fluids and pressor agents, oxygen,
blood, or glucose solutions .

9.  If respirations are shallow or labored or if
there is emesis with a threat of aspiration,
tracheal intubation and mechanical ventilation
are required.

10. The key components of the neurological
examination of the comatose patient
are:
 Examine level of consciousness (Glasgow
Coma Score
 The pattern of breathing
 size and reactivity of the pupils
 eye movements and oculovestibular
responses
 motor responses (tone, reflexes and
posturing)
 meningism and signs of the underlying cause

11. GENERAL EXAMINATION
 Consider the neurological findings in light of the
vital signs, evidence of trauma, acute or
chronic illness, and/or drug ingestion
 Cranial scars, drains, ICP monitors and VP
shunts.
 Neck stiffness
 Infusions (e.g. sedatives, nimodipine,
vasopressors)
 ventilator (type , mode , setting, evidence of
spontaneous breaths)

12. GCS : The Glasgow Coma Scale, constructed originally as a
quick and simple means of quantitating the responsiveness of
patients with severe cerebral trauma, can be used in the grading of
other acute coma-producing diseases.

13. PATTERN OF BREATHING
 Cheyne-Stokes respiration is not specific
but is seen in lesions above the brainstem.
 Central hyperventilation, or prolonged
inspiratory pauses or irregular ataxic
breathing indicates various brainstem lesions
as does apnea.
 Also look for deep rapid Kussmaul
breathing, secondary to a metabolic acidosis,
as in diabetes ketoacidosis.
 Look for spontaneous breaths in the
ventilated patient .

15. PUPILLARY RESPONSES
 Assess the pupils for size, asymmetry and
reactivity to light.
 Different sized pupils correspond to different types
of lesions.
 pinpoint pupils occur in pontine lesions and
certain overdoses (e.g. opioid, clonidine).
 fixed mid-sized pupils occur in midbrain lesions
 One dilated pupil suggests CN3 compression –
e.g. ICH, aneurysm or raised ICP.

17. OCULOVESTIBULAR
REFLEXES
Oculocephalic reflex (‘doll’s eye’
reflex)
 The patient’s eyes are held open
 The head is briskly turned from side to side
with the head held briefly at the end of each
turn.
 A positive response occurs when the eyes rotate
to the opposite side to the direction of head
rotation, thus indicating that the brainstem
(CN3,6,8) is intact.
 a similar result is seen when the head is flexed
and extended — a positive result is downward
deviation of the eyes during extension, and
upward deviation during flexion These vertical
responses indicates that the brainstem (CN3,4,8)
is intact.

18. • The eyes
should gradually
return to the mid-
position in a smooth,
conjugate
movement if the
brainstem is intact.
• Patients with
metabolic coma
(e.g. hepatic failure)
may have
exaggerated, brisk
oculocephalic
reflexes.

19. Oculovestibular reflex (caloric
stimulation)
 the head is elevated to 30 degrees above
horizontal so that the lateral semicircular canal is
vertical, and so that stimulation with generate a
maximal response.
 Introduce iced water into the external ear
canal through a small cather until one of the
following occurs:
— nystagmus (in the intact brainstem the slow
phase is towards the irrigated ear)
— ocular deviation
— 200mL of iced water has been instilled
 allow 5 minutes between testing ears to allow re-
equilibration of the oculovestibular system.

21. MOTOR RESPONSES
 POSTURING can occur spontaneously or in
response to a stimulus.
 Abnormal flexion is decorticate posturing —
adduction of arm, internal rotation of shoulder,
pronation of forearm, flexion of wrist (lower limbs
are extended); indicates a lesion above the
brainstem.
 Extension is decerebrate posturing — abduction
of arm, external rotation of shoulder, supination of
forearm, extension of wrist (lower limbs are
extended); indicates a lesion extending to the
midbrain or below.

23.  Assess for:
 Tone
 Clonus
 Deep tendon reflexes
 Planter reflexes
 involuntary movements (such as subtle signs
of seizures and myoclonus)

24. Investigations:
 If trauma, signs of raised ICP or focal
neurological signs and meningism is
suspected,
 Then CT Scan , Lumber puncture- CSF
examination is done.
 Skull X-Ray : to find out unsuspected
fractures, calcification or an osteolytic lesion.

25.  Chest X –Ray : may reveal bronchial
carcinoma.
 Electroencephalography:
may provide evidence of : Epilepy,
Encephalitis, Metabolic encephalopathy.
 MRI : it has a very less role in the
investigation of coma.