Management of Unconscious patients are one of the most difficult task to undertake. It emanate from striking out the cause of the condition and with the definitive management. The laboratory test to conduct also bring out a key results not even talking of the thorough clinical examination on the patient. This has called for the need to update knowledge around such cases to limit fatalities in managing such cases.

1. Management of
unconscious patient
MRS. Sarah Abrokwaah
MIDWIFERY OFFICER
St. Luke Hospital via Kasei, Ejura
Ghana-West Africa

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

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

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

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

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

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

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. Meningococcemic rashs

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; 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
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

51. Thank you for your attention