Management of-unconscious-patient Definition of unconsciousness Common causes Diagnosis and treatment of unconscious patient 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.

1. Management of
unconscious patient
By:
Nidhi Maurya
Era’s college of nursing
M.Sc. Nursing 1st year

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
a. Hypoxia
b. Ischemia
c. Hypoglycemia
 Alteration of neurophysiologic responses of neuronal
membranes
a. Drug intoxication
b. Alcohol intoxication
c. Epilepsy

7. Common Causes II
 Abnormalities of osmolarity
a. Diabetic ketoacidosis
b. Nonketotic hyperosmolar state
c. Hyponatremia
 Hepatic encephalopathy
 Hypertensive encephalopathy
 Uremic encephalopathy

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

9. An unconscious 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
• Rhythmed
• 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 Response
6 - 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. Meningococcemia
rash's

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 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.

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; rupture of an
internal carotid artery aneurysm

39. Fundoscopic examination

40. Fundoscopic examination
 Subarachnoid hemorrhages
 Hypertensive encephalopathy
 Increased intracranial pressure

41. Laboratory examination
Chemical blood determinations are
made routinely to investigate
metabolic, toxic or drug induced
encephalopathies.
-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 in
unrecognized 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.

48. Complaints Diagnosis Action
History of diabetes, use of oral
anti-diabetic or ingestion of
alcohol
* Hypoglycaemia • *Test blood for glucose using
test strip or glucose meter.
• Give IV Glucose
History of ingestion of
medication (tablets or liquid).
There may be smell of alcohol
or other substance on breath
Drug overdose.
e.g. Alcohol,
• Support respiration
• 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

49. Complaints Diagnosis Action
Presence or absence of history
of diabetes;
- polyuria, polydipsia
- hyperventilation
- gradual onset of illness
- evidence of infection
- Urine sugar and ketone
positive
- Blood glucose> 250 mg/dL
* Diabetic ketoacidosis • *Give Soluble Insulin and
Sodium Chloride 0.9% infusion
Fever, fits, headache, neck
stiffness, altered
consciousness etc
* Meningitis or Cerebral Malaria • *Treat with antibiotics and
quinine until either diagnosis
confirmed.
History of previous fits, sudden
onset of convulsions; with or
without incontinence.
* Epilepsy • *Give Diazepam, IV, to abort
fits and continue or start with
anti-epileptic drug treatment

50. Patient with hypertension or
diabetes; sudden onset of
paralysis of one side of body.
* Stroke • Check blood pressure and
blood glucose.
Patient with hypertension,
headaches, seizures
* Hypertensive encephalopathy • Check blood pressure
• If very high, give oral or
parenteral anti-hypertensives
Complaints Diagnosis Action