medical emergency- The unconscious patient and patient with altered consciousness

1. THE UNCONCIOUS PATIENT/ PATIENT
WITH ALTERED CONCIOUSNESS

2. HISTORY FROM PATIENT OR
BYSTANDER
TO DIRECT TOWARDS DIAGNOSIS
1. Alcohol abuse & Drug abuse
2. Hypertension
3. Diabetes & Fasting
4. Fever
5. Epilepsy
6. Urine output & bowel opening
7. Head injury

3. VITAL PARAMETERS
• RR
• PR
• BP
• Temperature
• Capillary Blood Sugar

4. ANALYSIS of HISTORY
If Alcohol abuse +
? Hepatic Encephalopathy
? Wernicke’s Encepalopathy
? Intoxication ( smell +)

5. ANALYSIS of HISTORY
If Drug abuse +
? Over dose

6. ANALYSIS of HISTORY
If Epilepsy +
ask what antiepileptic drugs
compliance?

7. ANALYSIS of HISTORY
If Hypertension +
? Stroke
? Hypertensive Encephalopathy

8. ANALYSIS of HISTORY
If Diabetes +
? Hyperglycemia- DKA/ HONK
? Hypoglcemia

9. ANALYSIS of HISTORY
If Fever +
? Meningitis
? Encephalitis
? Cerebral Malaria
? Septic Shock

10. ANALYSIS OF HISTORY
LOW/ NO urine output -
? ARF- measure BP immediately, catheterize &
monitor UOP
? Shock
NO bowel opening-
? Hepatic encephalopathy

11. Blood pressure ( 100/70- 140/90)
• High in stroke and Hyertensive Encephalopathy
• Low in shocks ( with tachycardia)
hypovolaemic shock
anaphylactic shock
septic shock
cardiogenic shock

12. Pulse rate (60- 100/min)
• High in Shocks & infection

13. Respiratory rate
• High in shocks & infection
• Low in intoxication

14. Temperature (98.4 ‘ F)
• High in infection
• Low in all shocks except septic shock
CBC, U.RE, MP & WIDAL IS MUST

15. GENERAL MANAGEMENT OF
UNCONCIOUS PATIENT
A B C D
1. AIRWAY- Maintain Patency
remove FB & denture
suck out secretion stat and 2- 4 hrly
prop up ( not in shock or cardiac arrest
patients)
lateral semiprone position

16. 2. BREATHING- Look for adequacy . If not
adequate-
ventilate with ambu bag and O2
connected
if no improvement- intubate

17. 3. CIRCULATION- Look for adequacy
No pulse- Start CPR
low BP- iv N.saline
iv cannulation is must ( possibly 2)

18. 4. DONOT FORGET CBS
treat hypoglycemia

19. Other important aspects
NG tubing- ? better not feed instead remove the
gastric content in most cases
Catherization- most patients need UOP monitoring
Eye care, mouth care, avoid constipation, skin care (
prevent bedsores)

20. HEPATIC ENCEPHALOPATHY
• Altered conciousness + alcoholic
Factors precipitation Hepatic Encepalopathy
1. Constipation & dehydration
2. Gastrointestinal bleeding
3. Infection
4. Diuretic therapy
5. Dietary protein overload
6. Renal failure
7. Medications: opiates, benzodiazepines,
antidepressants, and antipsychotic agents

21. Precipitants should be corrected
• Laculose 45 ml stat through NG tube then every
hourly dosing till bowel evacuation occurs.
Then adjust dose to produce 2-3 soft bowel
opening per day OR tap water enema to achieve
bowel opening
• hydration- iv 5% dextrose
with iv thiamine 100mg/ day till recovery

22. • Antibiotics- o. metranidazole 250 mg tds
• Protein withdrawn for 3 days. Then can take
40- 60 g/day
• Treat infection with broad sp Ab

23. WERNICKE’S ENCEPALOPATHY
• Altered conciousness + Alcoholic + these
features
• Eyes- Nystagmus, internal strabismus,
Nonreacting miotic pupils and complete loss
of ocular movements (in advanced cases) &
Ptosis.
• Gait- Abnormal

24. Old- Iv thiamine 100 mg daily for7 days,
followed by o thiamine as long as patient
drinks
New- Iv thiamine 500 mg tds for 3 days… partial
response 250 mg tds for 5 days

25. DKA and HONK
Altered conciousness + history of diabetes or
high CBS

26. DKA
Rehydration is more important than glycemic
control
Monitor PR, BP & UOP to guide rehydration

27. fluid
• N. saline 1L over 1 Hr
1L over 2 Hr
1L over 4 Hr & 6 Hr

28. insulin
• Iv infusion of soluble insulin is prefered ( but we
don’t have infusion pump! )
• Im soluble insulin 10- 20 units stat
then 10 units hrly guided by CBS before
administration ….till CBS 200 mg /dl but keep
monitoring
Add all…. Divide by 3 and give as tds dose by
subcut
Adjust subcut dose by sliding scale
Add kcl to 2nd bag of N. saline

29. HONK

30. Manage precipitating factor
1. Infection
2. Dehydration
3. Trauma & surgery
4. MI
5. Poor compliance

31. HYPOGLYCEMIA
SYMPATHETIC
OVERACTIVITY
• Tachycardia
• Palpitation
• Sweating
• Anxiety
• Cold exteremities
NEUROGLYCOPENIA
• Confusion
• Convulsions
• coma

32. Is the patient having
1. Diabetes?
2. Aute liver failure?
3. Alohol intoxication?

33. 50% dextrose 50-100 ml bolus OR im glucagon
1mg stat
If not available
25% dextrose 100 ml bolus
Continue iv infusion of 5% dextrose

34. ACUTE LIVER FAILURE
Altered consciousness + hypoglycemia + icteric
Bleeding tendencies
Acidotic breathing
Test- LFT, PT/INR/ hep serology/ blood grouping
& crossmatching

35. CBS- 2 Hrly- correct with 25% dextrose
Iv vit k 10 mg stat
Iv Ranitidine 50mg 8 Hrly
o. Metra 200 mg 8 Hrly
Lactulose 45 ml tds
Treat sepsis, seizure & cerebral edema
If bleeding- fresh blood Transfusion

36. MENINGITIS
Altered conciousness + fever
• Headache
• Neck stiffness
• Positive kernig’s sign
• Photophobia
• Focal neurological deficit
• Fits

37. 1.Empirical antibiotics
iv ceftriaxone 2g 12 hrly (if not available)
iv ampicillin 2 g stat & 4 Hrly + iv chloram 1 g stat
& 6hrly for 10 days
Iv C pen 4 mu stat & 4hrly+ iv chloram 1 g stat &
6hrly for 10 days
2. iv dexa 8 mg stat & 6 Hrly for 3 days. given 15 min
prior to iv ab
3. Treat fever, vomiting, seizure & raised intracranial
pressure as needed

38. ENCEPHALITIS
Similar to meningitis
Iv acyclovir 10mg/kg over 1 hr & 8 Hrly for 10
days

39. CEREBRAL MALARIA
Altered Conciousness + fever + urgent MP
positive or RDT positive
• Hypoglcaemia- monitor CBS 3 Hrly
• Shock monitor PR, BP, RR, Temp 6 hrly
• Anaemia infusion rate
• Seizure

40. Iv Quinine
loading dose- 20mg/kg in 10ml/kg of
5%dextrose over 4 Hr
Maintance dose- 10mg/kg 8 Hrly rate not
exceeding 5mg/kg/Hr (2-4hr)
iv for minimum of 48 Hr. Once oral possible
O. Quinine- 10mg/kg (600mg) 8 Hrly with
Clindamycin 20mg/kg/ day/3 for 7 days
O.doxy 200mg daily

41. Im Quinine
10 mg/kg 4 Hrly , better 8 Hrly
Im Artemether
3.2 mg/kg stat, then 1.6 mg/kg daily for 3 days
Iv / im Artesunate
2.4 mg/kg stat, then 1.2 mg/kg after 12 Hr, then
same dose daily for 3 days

42. Treat fever, hypoglycemia, anaemia, shock &
seisure

43. STROKE & TIA
Altered conciousness with neurological deficit and
high blood pressure
• Stroke- sudden onset of focal or global
neurological deficit lasting more than 24hr
due to vascular event.
• TIA< 24 Hr
• Stroke subtypes-
ischaemic 80%, IC hemorrhagic 15%, subarach
5%

44. Ischaemic vs Hemorrhagic stroke

45. HYPERTENSIVE ENCEPALOPATHY
Altered conciousness + high BP ( typically over
200/ 120)
• fundoscopic changes
• Hx of headache & blurring of vision
Iv frusemide 40- 80 mg
Aim is to reduce DBP to 100mmHg over 1-2 Hrs

46. EPILEPSY
Status Epilepticus- seisure lasting longer than
30mins or repeated fits without regaining
conciousness
All seisures should be treated as Status
Epilepticus

47. • Iv lorazepam 0.1 mg/kg (4mg)OR
• Iv diazepam 0.2 mg/kg (10mg)OR can be given
twice
5-10mins apart
• Per rectal diazepam 0.5mg/kg
5 min 10 min
Per rectal paraldehyde 0.4 ml/kg (10 ml rectally or 5ml im to each buttock)
10 min
Iv Phenytoin 18 mg/kg over 20 min OR
Maintainance with Iv Phenytoin 100mg 8 Hrly
Iv Phenobarbitol 15 mg/kg (< 3months or on phenytoin)
20 min
Consult Anaesthetist or Physician at JDWNRH

48. • Correct hypoglycemia
• If alcoholic- thiamine before glucose
• Remember to keep ambubag, oropharyngeal
airway, laryngoscope & ET tube ready….
all drugs used in status epilepticus can cause
respiratory depression

49. This is the second last slide
A THING TO REALIZE
Nurses are not servants to a doctor (they are
team- mates) nor they are programmed robots.
They are professional individuals in the field of
nursing, capable of analyzing problems in the
patients and taking appropriate step, be it a life
saving procedure, stabilization, medication,
monitoring, or informing a doctor.
In one way they have won a ticket to earn good
‘karma’ which other professions strive to achieve.

50. THANK YOU