This document provides information on rational prescription and the emergency management of unconscious patients. It discusses the steps involved in rational prescribing, including making an accurate diagnosis and choosing an appropriate treatment. It also defines different levels of consciousness from full consciousness to coma. Common causes of unconsciousness and the ABCDE approach for initial management are outlined. Assessment involves a detailed neurological examination and relevant diagnostic tests. Treatment depends on the underlying cause but always aims to support respiration, circulation, and other vital functions while the patient's condition is closely monitored.

1. D R . S O N D I P O N M A L A K E R
M O , M U - 2
TA N G A I L M E D I C A L C O L L E G E H O S P I TA L .
Rational Prescription
and
Emergency management of
Unconscious Patient

2. RATIONAL PRESCRIPTION

3. Rational prescription…
 Rational prescription means patient will receive the
appropriate medicine according to the disease, in proper
dose in proper formulation for an adequate period of time
at the lowest cost to them & their community.

4. Steps of rational prescribing:
 Make a diagnosis.
 Consider factors influencing patient’s response to therapy.
 Establish the therapeutic goal.
 Choose the therapeutic approach.
 Choose the drug & its formulation.
 Choose the dose, root, frequency .
 Choose the duration of the therapy.

5.  Write an unambiguous prescription.
 Inform the patient about the treatment & its likely effects.
 Monitor the treatment effects both harmful & beneficial.
 Review or alter the prescription.

6. Rational prescribing includes…
 Sometimes not prescribing any drug at all..
 Good prescribing is not simply matching the disease and
the drug….
 Individualize the therapy….

7. Elements of prescription:
 Name of the prescriber
 Professional degree
 Address
 Date of prescription
 Name of the patient
 Address of the patient
 Drug name

8.  Strength of the drug
 Quantity of the drug
 Route & method to be administration
 Advise
 Prescriber’s signature
 License no. or registration no.

9. Rational prescribing requires:
 Diagnostic skills.
 Knowledge of medicines.
 Detailed knowledge of the pathophysiology of the disease
of the patient.
 Clinical pharmacology of the drugs you are intended to
use.
 Evidence based practice.
 Individualization of risk-benefit ratio.
 Communication skills.

10.  Common prescribing errors:
 Omission of needed information
 Poor prescription writing
 Inappropriate drug prescription

11. What contribute to irrational prescribing
Prescribers:
 Inadequate examination of the patient.
 Inadequate communication between patient & doctor.
 Lack of documented medical history.
 In adequate laboratory resources.
 Work overload of doctors.
 Prescribing incentives from Pharmaceutical companies.

12. Health care system:
 Lack of measurement of quality of prescription.
 Lack of evidence based clinical guidelines and
prescription policies.
 Inadequate training of undergraduates regarding
prescribing.
 Inadequate drug supply and health care personals.
 Unethical promotion of pharmaceutical products.

13. Types of irrational Drug use:
 Under prescribing
 Over prescribing
 Incorrect prescribing.
 Multiple prescribing

14. Consequences of Irrational prescribing
 Low chances of benefit.
 Polypharmacy.
 Irrational use of antibiotics.
 Risk of ADR and drug-drug interactions.
 Waste of resources
 Inappropriate treatment

15. Impact of Irrational Prescribing
a. Delay in cure
b. More Adverse Effects
c. Prolonged Hospitalization
d. Emergence of antimicrobial resistance
e. Loss of patient’s confidence in the doctor
f. Economical burden for the patient & the community
g. Lowering of health standards

16. Polypharmacy
 Concomitant use of multiple drugs.
 Mainly seen in elderly patients.
 Polypharmacy can be-
Appropriate
Inappropriate- most of the time.

17. Potential risk of polypharmacy:
 Increased risk of ADR and Drug resistance.
 Poor adherence to drug.
 Waste of money.

18. Managing polypharmacy:
 Non pharmacological approach.
 Avoid prescribing for minor, non specific or self limiting
conditions.
 Regular medication review.
 Simplify the treatment.
 Talk with patients about their personal choice.

19. Irrational use of Antibiotics
 Overuse
 Underuse
 Inappropriate use
 Promotion by drug companies
 Lack of antibiotic policies, guidelines and regulations to
control inappropriate antibiotic use.

20. How to promote rational use of antibiotic:
 Educating the prescribers about the rational use of
antibiotics.
 Encouraging restrictions in prescribing antibiotics to
selected antibiotics.
 Promote review of antibiotic treatment during course of
illness.
 Audits and feedback.
 Improved diagnostic services.

21.  Developing antibiotic policies and treatment guidelines.
 Regulation on quality and drug promotion.
 Surveillance of resistance pattern.
 Using local surveillance data in clinical management and
to update treatment guidelines.

22. RATIONALIZATION OF
PRESCRIPTION PRACTISES
 Most of the illness responds to simple, inexpensive drugs.
 Physician should avoid:
 use of expensive drugs.
 use of drugs in nonspecific condition
(e.g. use of vitamins)
 use of not required forms
(e.g. injections in place of capsules , syrup in place of tablets)

23. WHO model for rational prescribing

24. P- drug concept
 P drugs (Personal drugs) are the drugs, you have chosen to
prescribe regularly , with whom you have become
familiar.
 they are your drugs of choice for given indications.
 Choosing and using only 50-60 drugs only among 1000s.

25. Selecting a P- drug
 Step -1: Define the diagnosis
 Step -2: Specify the therapeutic objective
 Step- 3: Make an inventory of effective groups of drugs
 Step-4: Choose an effective group according to criteria
 Step-5: Choose P- drug

26. ADVANTAGES OF P- DRUG
 More convenient
 More confidence
 Can be able to master easily
 Drug effects are predictable
 Less chance of unexpected adverse effects and drug
interactions
 Less complication

27. ADVANTAGES OF P- DRUG
 Possibility of adopting rational drug use
 Less burden on the physician
 Health care delivery is easy
 Less health care costs

28. EMERGENCY MANAGEMENT OF
UNCONCIOUS PATIENT

29.  In hospital emergency, the clinical analysis of
unresponsive unconscious patient is always an urgency.
 Physicians must therefore be prepared to implement a
rapid, systematic approach for prompt therapeutic action.

30. NEURAL BASIS OF CONSCIOUSNESS
 Maintenance of consciousness depends on interaction
between ascending reticular activating system (ARAS) &
cerebral hemispheres.
 ARAS extends from the lower border of the pons to the
ventromedial thalamus & then project to the whole
cerebral cortex.

31.  It receives collateral from the spinothalamic & the
trigeminal thalamic pathways.
 Disorders that distort normal anatomical relationships of
the mid brain, thalamus, and cortex appear to impair
arousal.

33. TERMINOLOGY
 Consciousness
 Confusion
 Drowsiness
 Stupor
 Coma

34. CONSCIOUSNESS
 It means the state of the patient’s awareness of self and
environment and his responsiveness to external
stimulation and inner need.

35. CONFUSION
 Traditionally referred as “ CLOUDING OF
SENSORIUM.”
 It denotes inability to think with customary speed clarity
and coherence accompanied by some degree of
inattentiveness and disorientation.
 Confusion results most often from process that influence
the brain globally. Such as toxic or metabolic disturbance
or a dementia.

36. DROWSSINESS
 It is inability to sustain a wakeful state without
application of external stimuli.
 Slow arousal is elicited by speaking to patient or applying
a tactile stimulus.

37. STUPOR
 Stupor can be described a state in which the patient can be
aroused only by vigorous and repeated stimuli.
 Response to verbal command is either absent or slow and
inadequate.
 When left unstimulated, these patients quickly drift back
into a sleep like state.

38. COMA
 Coma is a deep sleep like stage from which patient can
not be aroused to respond appropriately to stimuli even
with vigorous stimulation.
 The patient may grimace in response to painful stimuli
and limbs may show stereotyped withdrawal response, but
patient does not make localized responses.

39. COMMON CAUSES OF UNCONSCIOUSNESS
 Head injury
 Cerebrovascular disease
 Meningoencephalitis
 Cerebral abcess
 Diabetes melitus
 Hypoglycemia
 Ketoacidosis
 HHS
 Uremia
 Hepatic failure
 Sepsis
 Drugs
 Hypothermia
 Electrolyte imbalance
 Myxoedema coma
 Cerebral hypoxia
 Cardiac arrest

40. INITIAL MANAGEMENT OF UNCONSCIOUS
PATIENT ON ARRIVAL
ABCDE approach:
 Airway
 Breathing
 Circulation
 Disability
 Exposure

41. AIRWAY
 Evaluate – is airway patent? Is there any trauma or foreign
body obstruction in airway?
 Patient with head injury may also have suffered a fracture
of cervical vertebra, in which caution must be exercised
during examining head neck.
 If breathing is easy- oropharyngeal airway is sufficient
 If respiration is shallow or labored or chance of aspiration
intubation is needed.
 Head tilt & chin lift maneuver.

42. BREATHING
 Evaluate- is respiration adeuate? Is gas exchange
adequate? Are breath sounds are adequate & symmetrical?
 Must assure oxygenation& ventilation.
 Identify and immediately treat problems- pneumothorax,
airway obstruction,etc.

43. CIRCULATION
 Is patient in shock?
 check pulses,
 heart rate,
 BP,
 capillary refill time
*remember hypotension is late sign of shock
 Start treatment of shock
 Do not restrict fluid in comatose patient with inadequate
intravascular volume.
 Use isotonic solutions & blood , as indicated.

44.  Don’t use hypotonic solutions to treat shock, particularly patient with
coma or cerebral edema.
 Identify life threatening hemorrhage & control it.
 Colloid has no role in volume replacement .
 Types of shock:
 Hypovolaemic
 Obstructive
 Cardiogenic
 distributive

45. HISTORY
 Inquire about-
 History of diabetes
 Hypertension
 Head injury
 Convulsions
 Alcohol or drug use
 Circumstances in which patient was found
 Medications in hospitalized patient like anesthetics, antiepileptic,
opiates, antidepressants, antipsychotics.

46.  Onset of unconsciousness:
 Sudden onset- vascular origin especially brainstem stroke or SAH.
 Rapid progression from hemispheric signs to coma- intracerebral
hemorrhage.
 Protracted course- tumor, abscess, chronic SDH.
 Coma preceded by confusional or agitated state & without
lateralizing signs- metabolic cause.

47. GENERAL EXAMINATION

48. GENERAL EXAMINATION
 Signs of trauma-
 Raccoon eyes
 Battle’s sign
 CSF rhinorrhea or otorrhea
 Blood pressure-
 Hypertension suggests:
 Hypertensive encephalopathy
 Intracerebral hemorrhage

49.  Hypotension suggests:
 Myocardial infarction
 Septicemia
 Addison disease
 Alcohol or barbiturate poisoning
 Internal hemorrhage.
 Temperature:
 Hypothermia suggests:
 Alcohol or barbiturate intoxication
 Myxedema
 Advanced Tubercular meningitis
 Peripheral circulatory failure

50.  Hyperthermia suggests-
• Systemic infection
• meningoencephalitis
• heat stroke
• anticholinergic drugs abuse
 Pulse- bradycardia with periodic breathing and
hypertension (Cushing Reflex) suggests raised ICP.

51.  Skin inspection:
• Rash
• Excessive sweating
 Odour of breath:
• DKA
• Hepatic encephalopathy
 Evidence of any systemic illness
 Heart-lung

52. Neurological examination
 Asses level of consciousness: by GLASGOW COMA
SCALE.
 Signs of meningeal irritation-
• Meningitis
• SAH
 Fundus:
• Raised ICP
• SAH
• Hypertensive encphalopathy

53. Papilloedema

54. Subarachnoid Hemorrhage

55. Hypertensive retinopathy

56.  Pupil size and response to light
 Occular movements
 Posture and limb movement:
 Decorticate posture
 Decerebrate posture
 Reflexes

58. Glasgow Coma Scale
 Three components. Score derived by adding the score for
each component.
 Eye opening (4 points)
 Verbal Response(5 points)
 Best motor response(6 points)

59.  Eye opening
 4- spontaneous
 3-to speech
 2-to pain
 1-none
 Verbal response
 5-oriented
 4- confused conversation
 3-inappropriate words
 1-none
 Best motor response
 6-obeys
 5-localizes
 4-withdrawal
 3-abnormal flexion
 2-abnormal extension
 1- none
Glasgow Coma Scale

60. Laboratory investigations

61.  Lab investigations are done to confirm the provisional
diagnosis and to exclude the differential diagnoses.
 There are several investigations but the physician should
be specific what investigations should be appropriate for
the patient.
 Detailed history and clinical examination will guide the
physician to choose that investigations.

62.  Chemical blood determinations are made routinely to
investigate metabolic, toxic or drug induced
encephalopathy.
 Blood urea & Electrolytes
 Serum Creatinine
 Random blood glucose
 Drug levels
 Toxicological screen
 LFT
 Thyroid function test

63.  Arterial blood gas analysis
 CBC
 Blood C/S
 Urine C/S
 Malaria screening
 Imaging: in coma of unknown etiology CT or MRI must
be performed to detect-
 Ischemic stroke
 Hemorrhage
 Tumor & hydrocephalus

64.  Lumbar puncture : to diagnose-
 Meningitis
 SAH
 ECG

65. Treatment
 Treatment should be focused according to cause. But
whatever the cause, long term attention is required to
maintain patient’s respiration, Circulation, skin, bladder &
bowel function, seizure must be controlled and the level
of consciousness should be regularly assessed. If patients
condition is deteriorating or not improving patient should
be shifted to ICU.

66. THANK YOU!!!!