How to approach an unconscious patient? Management not included. intended for 4th year/5th year MBBS students.

1. APPROACH TO UNCONSCIOUS
PATIENT
Dr. Tanveen Kamal
Assistant Professor
Department Of Neurosurgery
Shahabuddin Medical College & Hospital

2. CONSCIOUSNESS, WHAT IS IT??
Consciousness is the state of full awareness of the self and one’s relationship to the
environment.
Clinically, the level of consciousness of a patient is defined at the bedside
by the responses of the patient to the examiner.
It is clear from this definition that it is possible for a patient to be conscious yet not
responsive to the examiner.
For example,
• if the patient lacks sensory inputs,
• is paralyzed (Locked In Syndrome),
• or for psychologic reasons
decides not to respond

3. WHAT IS SLEEP ,THEN?
Sleep is a form of reduced consciousness in which the responsiveness of
brain systems responsible for cognitive function is globally reduced,
So that the brain does not respond readily to environmental stimuli.
Pathologic alteration of the relationships between the brain systems that
are responsible for wakefulness and sleep can impair consciousness.
A key difference between sleep and coma is that sleep is intrinsically
reversible:
sufficient stimulation will return the individual to a normal waking state

4. SO……WHO IS UNCONSCIOUS ???
Patients who have a sleep like appearance and remain
behaviorally unresponsive to all external stimuli are unconscious
by any definition.
• Impaired consciousness is among the most difficult and
dramatic of clinical problems.
The brain tolerates only limited physical or metabolic injury, so that
impaired consciousness is often a sign of impending irreparable
damage to the brain.

5. TERMS USED TO DESCRIBE
DISORDERS OF CONSCIOUSNESS
Acute Chronic
Clouding
Delirium
Obtundation
Stupor
Coma
Locked in Syndrome
Dementia
Hypersomnia
Abulic
Akinetic mutism
Minimal consciousness
Vegetative State
Brain Death

6. PROBLEMS WITH DIFFERENT TERMS….IT’S
CONFUSING!!
• A wide variety of systemic and intracranial problems produce
depression of conscious level.
• Accurate assessment and recording are essential to determine
deterioration or improvement in a patient’s condition
• In 1974 Teasdale and Jennett, in Glasgow, developed a system for
conscious level assessment.
• They discarded vague terms such as stupor, semi coma and deep
coma

7. And described conscious level in terms of
•EYE OPENING,
•VERBAL RESPONSE AND
•MOTOR RESPONSE

8. EYE OPENING -4 CATEGORIES
4
3
2 1

9. EYE OPENING -4 CATEGORIES-DESCRIPTION
Patient’s visual or eye response
 Score your patient a 4 if he/she can open their eyes spontaneously
 Score your patient a 3 if they open their eyes to verbal speech -“Mr. X”or
light touch
 Score your patient a 2 if your patient requires painful stimuli to open
their eyes
 Score your patient a 1 if their eyes do not open. Patient is unresponsive.

10. VERBAL RESPONSE- 5 categories
Patient’s verbal response (if intubated or tracheotomy score NT=not
testable / T=Tube)
Score your patient a 5 if patient is oriented x 3 (He or she knows who
they are, where they are, and what the date is)
Score your patient a 4 if you not they are having some confusion or
forgetfulness (unable to answer all orientation questions)
Score your patient a 3 if they are not understood and using inappropriate
words (i.e. swearing, unrelated words, aggressive)
Score your patient a 2 if they are not able to form words and just can
make sounds
Score your patient a 1 if they are unresponsive and make no noise

11. MOTOR RESPONSE
Motor Response -6 Categories
6

12. Localizing to pain
Apply a painful stimulus to the
supraorbital nerve,
e.g. rub thumb nail in the
supraorbital groove,
increasing pressure until a
response is
obtained
5

13. If the patient does not localize to
supraorbital pressure, apply
pressure with a pen or hard
object to the nail bed. Record
elbow flexion as
‘flexing to pain’.
4

14. Abnormal flexion to a painful stimulus typically involves
• Adduction of the arm,
• internal rotation of the shoulder,
• flexion of the elbow,
• pronation of the forearm and wrist flexion (known as decorticate
posturing).
3

15. • Abnormal extension to a painful stimulus is also known as decerebrate
posturing.
• In decerebrate posturing, the head is extended, with the arms and legs
also extended and internally rotated.
• The patient appears rigid with their teeth clenched.
• The signs can be on just one side of the body or on both sides (the signs
may only be present in the upper limbs)
2

16. GCS (Glasgow Coma Scale)

17. Examination of Unconscious patient-History
• Questioning relatives, friends or the ambulance team is an essential part
of the assessment of the unconscious patient
• Has the patient sustained a head injury – leading to admission, or in the
preceding weeks?
• Did the patient collapse suddenly?-Indicating that an acute problem is
more likely
• Did limb twitching occur?-Explain
• Have symptoms occurred in the preceding weeks?
• Has the patient suffered a previous illness?-DM/HTN/IHD
• Does the patient take medication?-Such as Antiplatelets/Anticoagulants

18. GENERAL EXAMINATION
Lack of patient co-operation does not limit general examination and this
may reveal important diagnostic signs.
In addition to those features, also look for
• signs of head injury,
• needle marks on the arm and
• evidence of tongue biting.
• Also note the smell of alcohol- beware of attributing the patient’s clinical
state solely to alcohol excess

19. NEUROLOGICAL EXAMINATION
• Conscious level: This assessment is of major importance. It
not only serves as an immediate prognostic guide, but also
provides a baseline with which future examinations may be
compared.
• Assess conscious level as described previously in terms
of eye opening,
verbal response and
motor response

20. • It is important to avoid the tendency to simply quote the patient’s
total score. This can be misleading.
• Describing the conscious level in terms of the actual responses
i.e.
• ‘no eye opening, no verbal response and extending’, avoids
any confusion over numbers

21. ADDITIONAL EXAMINATIONS
•Pupil response
•Funduscopy-if possible
•Corneal reflex
– tone
•Limb – reflexes
•Plantar response

22. IMPORTANCE OF PUPIL EXAMINATION
• The pupil size should be recorded in millimeters and the reactivity
documented as present, sluggish or absent
• UNCAL HERNIATION can compress the third nerve, compromising the
parasympathetic supply to the pupil.
• Unopposed sympathetic activity produces a sluggish enlarged pupil,
progressing to fixed and dilated under continued compression

23. Examination of EYE Movements- MUST Exclude
Cervical injury first

24. VESTIBULO-OCULAR REFLEX
Method: Water at 30°C irrigated into the external auditory meatus. Nystagmus
usually develops after a 20 second delay and lasts for more than a minute
The test is repeated after 5 minutes with water at 44°C.
Cold water effectively reduces the vestibular output from one side, creating an
imbalance and producing eye drift towards the irrigated ear.
Rapid corrective movements result in ‘nystagmus’ to the opposite ear. Hot water
(44°) reverses the convection current, increases the vestibular output and changes
the direction of nystagmus.

25. • Nystagmus is a condition in which the eyes make repetitive,
uncontrolled movements.
• These movements often result in reduced vision and depth
perception and can affect balance and coordination. These
involuntary eye movements can occur from side to side, up and
down, or in a circular pattern.

27. VISUAL FIELDS
In the unco-operative
patient, the examiner may
detect a field defect when
‘menacing’ from one side
fails to produce a ‘blink’

28. FACIAL WEAKNESS
Facial weakness
Failure to ‘grimace’
on one side in
response to bilateral
supraorbital pain
indicates a facial
weakness.

29. LIMB WEAKNESS
Detect by comparing the response in
the limbs to painful stimuli. If pain
produces an asymmetric response,
then limb weakness is present.
(If the patient ‘localises’ with one
arm, hold this down and retest to
ensure that a similar response
cannot be elicited
from the other limb.)

30. LOWER LIMBS
• Pain stimulus applied to the toe nails or Achilles tendon similarly tests power in
the lower limbs.
• Variation in tone,
• reflexes or
• plantar responses between each side also indicates a focal deficit.
• In practice, if the examiner fails to detect a difference in response to painful
stimuli, these additional features seldom provide convincing evidence

31. • Patients who do not meet all the discharge criteria will need admission for a further
period of observation and/or brain imaging.
GUIDELINES FOR COMPUTED TOMOGRAPHY (CT) IN HEAD INJURY.
Indications for CT imaging in head injury within 1 hour
● GCS <13 at any point
● GCS <15 at 2 hours
● Focal neurological deficit
● Suspected open, depressed or basal skull fracture
● More than one episode of vomiting
● Post-traumatic seizure
Indications for CT imaging within 8 hours
● Age >65
● Coagulopathy (e.g. aspirin, warfarin or rivaroxaban use)
● Dangerous mechanism of injury (e.g. fall from a height, RTA)
● Retrograde amnesia >30 minutes

32. QUESTIONS???