1. Approach to
The Unconscious Patient
Dr. Sharat S. Kolke
MD, DNB
Fauziya Hospital
Kohinoor Hospital

2. The Unconscious Patient
Wakefulness depends on the integrity
of both cerebral hemispheres and the
ascending reticular activating formation of
the brain stem.

3. The Reticular formation

4. The Reticular formation

5. Causes of Coma

6. Clinico-pathological approach
( A ) Localised mass lesions, ( B ) Diffuse neurona! lesions
producing pressure effect :
i) Infection
i) Supratentorial causing
herniation ii) Metabolic encephalopathies
ii) Infratentorial causing iii) Drug intoxication
compression
iv) Haemorrhage ( subarachnoid )
v) Trauma (generalised brain
oedema)
( C ) Psychiatric diseases
vi) Ischaemia ( anoxia )

7. Approach

8. General examination
Skin
(for example, rash, anaemia, cyanosis, jaundice)
Temperature
(fever-infection /hypothermia-drugs,
hypothyroid /circulatory failure)
Blood pressure
(for example, septicaemia/Addison's disease)

9. General examination
Breath
(eg, fetor hepaticus)
Cardiovascular
(eg, murmurs, arrhythmia)
Abdomen
(eg, organomegaly)
Neurological (general)
Head, neck and eardrum (trauma)
Meningism
(SAH/ meningitis)
Fundoscopy

10. Approach

11. Definition
Unconsciousness is defined as loss
of awareness of the environment and it can
be divided into three stages :
( a ) Obtundation; responds to verbal
stimuli although slow and inappropriate.
( b ) Stupor; the subject can be roused
only by vigorous and repeated noxious stimuli.
( c ) Coma; unarousable and unresponsive.

12. Level of consciousness
Glasgow coma scale
Eye opening
Verbal response
Motor response

13. Glasgow coma scale
Eye Opening
N ever 1
To pain 2
To verbal stimuli 3
Spontaneously 4
Best Verbal Response
No response 1
Incomprehensible sounds 2
Inappropriate words 3
Disoriented and converses 4
Oriented and converses 5
Best Motor Response
No response 1
Extension (Decerbration) 2
Flexion (Decortication) 3
Flexion withdrawal 4
Only localises pain 5
No response 6

14. Glasgow coma scale
More commonly used to assess the severity
of Brain injury
Lesser the score deeper the level on
unconsciousness
Coma is defined as a score of 8 or less

15. Brain Death
 Deep unresponsive coma
 Absence of brain stem activity
Large non reactive pupils
Absent corneal response
Absent of eye movements
Apnea in spite of pCo2 > 50mmHg
 Exclusion of drug overdose and/or
hypothermia

16. Respiratory pattern
( a ) Hyperventilation - usually indicating a
midbrain and upper pons lesion commonly
found in metabolic diseases e.g. hepatic
coma, diabetes and generalized raised
intracranial pressure in its early stages.
( b ) Hypoventilation - usually indicating a
medullary, upper cervical spinal lesion
commonly found in drug overdose and
later stages of cerebral herniation.

17. Respiratory pattern
( c ) Cheyne-Stoke respiration - usually indicating
a diencephalic lesion commonly found in
central transtentorial herniation and
obstructive,hydrocephalus.
( d ) Ataxic respiration (completely irregular
breathing) - usually indicating brain-stem
dysfunction of a diffuse nature.

18. Pupillary size and reaction
(a) Medium to dilated symmetrical pupils fixed
to light – structural disease of the brain stem.
(b) Small symmetrical pupils reactive to light -
metabolic diseases and drug overdose.
(c) Unequal pupil fixed to light - intracranial
mass lesion producing 3rd nerve palsy, e.g. in
unilateral uncal herniation.

19. Pupillary size and reaction

20. Eye movements
( a ) Vestibulo-ocular reflexes –
Douching of one ear with cold water produces ipsilateral
deviation of both eyes with a contralateral quick phase
nystagmus lasting for 1—2 minutes.
Use of hot water produces the opposite effect i.e.
contralateral deviation with ipsilateral quick phase
nystagmus.
Bilateral douching with cold water gives rise to
downward deviation with upward nystagmus and with
hot water the opposite response.
Absence or abnormal response indicates brain-stem
dysfunction.

21. Eye movements
( b ) Oculo-cephalic reflexes or (Doll's eye
movement ) –
Normal response consist of deviation of both
eyes to the opposite direction of head rotation.
Again absence or abnormal response
indicates brain-stem dysfunction.

22. Eye movements

23. 5. Motor responses
This is elicited by applying peripheral noxious
stimuli e.g. pinching of limbs, rubbing the
sternum to elicit pain.
(a) Appropriate response – brushing away the
source of stimulus.
(b) Inappropriate response – decerebrate or
decorticate rigidity. Motor response is also of
localising value
(c) Paralysed limb will show no response

24. 5. Motor responses
Decerebrate rigidity indicates brain-stem
damage and if bilateral is usually associated with
a very poor prognosis.
Complete flaccidity with no response to noxious
stimuli is often indicative of severe central
nervous system depression due to drug
overdose.

25. Investigations
Supratorial lesions -
1. Computerised tomographic scan ( CT scan )
2. Carotid DSA
3. EEG ( electroencephalogram )
Infratentorial lesions –
1. CT scan/MRI
2. Carotid or Vertebrobasilar DSA

26. Investigations
Diffuse neuronal lesions -
1. Examination of CSF ( cerebral spine fluid )
2. Serum glucose, calcium, Na+, K , magnesium
3. Blood gases and PH
4. Liver and renal functions
5. Drug levels

27. Management
Management of the comatose patient
depends on the cause.
However, while the patient is undergoing
evaluation, it is essential to :
1) Maintain adequate cerebral
oxygenation, patent air-way, assisted
respiration if necessary.

28. Management
2) Prevent aspiration - Nursing the
patient on the side and empty the
stomach.
3) Establish an intravenous Site for
prompt medication - e.g. !V
glucose/insulin; antibiotics; high
dose steroid; anticonvulsants.