Unconscious patient TYPES CARE

1. UNCONSCIOUSNESS

2. Coma ( or 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 results from gross
impairment of both cerebral
hemispheres, and/or the ascending
reticular activating system.

3. Alcohol
Epilepsy
Insulin
Overdose
Uremia (and other
metabolic causes)
Trauma
Infection
Psychiatric
Stroke, syncope
POSSIBLE CAUSES

4. ABC
Immediate management
Examination
History
Investigations
APPROACH

5. ABC
ABC
A –Open the
airway
B –breathing C –circulation

6. -Open, clear, maintain
-If trauma present or no history available,
immediately control C-spine
AIRWAY

7. -Assess presence, adequacy
-High concentration O2 immediately on all
patients with decreased LOC
-Assist if respiratory rate, tidal volume
inadequate
BREATHING

8. Pulses?
Perfusion?
bleeding?
CIRCULATION

9. Maintain i.v line, oxygen inhalation
Blood sample
Control seizures
IMMEDIATE MANAGEMENT

10. Allergies
Medication
Previous medical history (Epilepsy, Diabetes)
Last meal
Event - What has happened?
HISTORY

11. EXAMINATION
Examination
•Vitals
•Skin petechial rash
•Injection marks
•Neurological assessment
•Detailed medical
examination
Head, Thorax, Neck
Abdomen, limbs, back
Fundoscopy

12. 1.Pulse
Tachycardia
 Hypovolemia/haemorrhage
 hyperthermia
 Intoxication
Bradycardia
 Raised intracranial pressure
 Heart blocks
Vitals

13. Increased
 Sepsis
 Meningitis ,encephalitis
 Malaria , haemorrhage
Decreased
 Hypoglycemia
 Hypothermia
 Myxedema
 Alcohol, barbiturate ,sedative or phenothiazine
intoxication.
2.Temperature

14. Increased
 Hypertensive encephalopathy
 Cerebral haemorrhage
 Raised intracranial pressure
Decreased
 Hypovolemia
 Myocardial infarction
 Intoxication/poisoning
3.Blood pressure

15. Increased
 Pneumonia
 Acidosis (DKA, renal failure)
 Pulmonary embolism
 Respiratory failure
Decreased
 Intoxication/poisoning
4.Respiratory rate

16.  Meningococcal meningitis
 Endocarditis
 Sepsis,thrombotic thrombocytopenic purpura
Skin petechial rash

17.  Drug addiction
 Acute endocarditis
 Hepatitis B /C with encephalopathy
 HIV
Multiple injection marks

18. Neurological assessment;
1)General posture
2)Level of conciousness
CONTD.

19. 1)Posture;
 Lack of movements on one side
 Intermittent twitching
 Multifocal myoclonus
 DECORTICATION
 DECEREBRATION
CONTD.

20. 2)Level of conciousness
 Glasgow coma scale (GCS)
Best motor response
Best verbal response
Eye opening
-GCS score 3 –severe injury
-less than or equal to 8 – moderate injury
-9 to 12 – minor injury
CONTD.

21. • Eyes open
1. Never
2. To pain
3. To verbal stimuli
4. spontaneously
• Best verbal response
1. No response
2. Incomprehensible sounds
3. Inappropriate words
4. Disoriented and converses
5. Oriented and converses
• Best motor response
1. No response
2. Extension (decerebrate rigidity)
3. Abnormal flexion (decorticate rigidity)
4. Flexion-withdrawal to pain
5. Localizes pain
6. Obeys commands
GLASGOW COMA SCALE
MONITORING LEVEL OF CONSCIOUSNESS (SCORE 3-15)

22. PUPILLARY CHANGES
pupils causes
B/L small pupils -Opiates poisoning ,extensive
pontine.
-Metabolic encephalopathies ,deep
B/L hemisphere leison
B/L dilated and fixed -Severe midbrain damage, Overdose
of atropine
U/L small pupil Horner syndrome

23. Skull for irregularity or scalp wounds
Ears (blood or CSF)
Eyes for pupil size and reaction (PEARL)
Lips for colour (cyanosed)
Jaw for displacement
Mouth for loose or missing teeth or bitten
tongue (Epilepsy)
Skin colour, texture and temperature (Flushed,
Dry and Hot) etc
HEAD, CHECK:

24. Clavicles for bruising and possible
fractures
Sternum
Ribs - fractures and abnormal breathing
Neck rigidity- Meningitis
THORAX, NECK

25. Rigidity and guarding
Pulsating masses
Bruising
Pelvis fractures or abnormal
movement
Groin for dampness
ABDOMEN, CHECK:

26. Irregularity, deformity and fractures
(compare limbs with each other)
Flexion and extension without
aggravating any injury
Signs of drug abuse (Needle marks)
Identity bracelets
Capillary refill and distal pulses
LIMBS, CHECK:

27. Scapulae for fractures
Spine for irregularities
BACK, CHECK:

28. Raised intracranial pressure
Hypertensive changes
Subarachnoid haemorrhage
Diabetic retinopathy
FUNDOSCOPY

29.  Respiratory Rate
 Pulse Rate
 Blood Glucose Levels
 Oxygen Saturations
 Temperature
VITAL SIGNS - MONITOR

30.  CBC
 Blood ESR
 LFTs
 Urea and Creatnine
 Blood and urine cultures
IMMEDIATE INVESTIGATIONS

31.  CRP
 ABGs
 Toxic screen , drug levels
 Lumbar puncture and CXR
 CT scan
OTHER INVESTIGATIONS

32. Management
depends on the
cause

33. ABC of life support
Oxygen and I.V access
Stabilize cervical spine

34. Blood glucose
Control seizures
Consider I.V glucose, thiamine, naloxone,
flumazenil
CONTD.

35. Brief examination and obtain history
Investigate
Reassess the situation and plan further
CONTD.

36.  Respiratory function: Position the patient in the lateral
recumbent position to prevent the occlusion of the airway from
the tongue falling back against the pharyngeal wall.
 Dentures should be removed and note made of any loose teeth or
crowns that may become dislodged and compromise the airway.
 Elevate the head of bed to 30 degrees to facilitate the drainage of
secretions from the mouth.
 Avoid feeding orally.
 Remove excess oral secretions with suction to avoid aspiration.
 Consider the use of an oral or nasopharyngeal airway, to maintain
patency of the airway and to aid removal of secretions.
 Monitor and record respiratory function, including oxygen
saturations, respiratory rate, depth and regularity.
 Physiotherapy is important to encourage lung expansion

37.  Neurological status: Regular Glasgow Coma Scale assessment
should be recorded, including pupil and limb assessment.
 Cardiovascular function: Monitor heart rate and rhythm,
blood pressure and temperature.
 Be aware of any changes in vital signs that indicate further
neurological deterioration.
 Observe the patient for any changes in colour, for example,
 pallor or cyanosis, including the peripheries.
 Observe for signs of infection, including pyrexia, tachycardia and
hypotension.

38.  Immobility: Reposition the patient regularly following
assessment of pressure areas and respiratory function.
 Assess monitor skin integrity.
 Consider the use of anti-embolism stockings and anticoagulants
for venous thromboembolism prophylaxis.

39.  Pain: Observe for signs of pain or discomfort.
 Aim to alleviate, consider repositioning the patient or
administering
analgesia as prescribed.
Monitor the effectiveness of any intervention.
 Renal function: Insert a urinary catheter to avoid urinary
stasis.
 Monitor urine output hourly.

40.  Gastrointestinal needs / Nutrition and hydration:
 Consider enteral feeding to provide nutritional support.
 Monitor and record fluid balance and
 administer intravenous fluids as prescribed.
 The insertion of a nasogastric tube in the early stages of
unconsciousness will allow removal of gastric contents, thus
reducing the risk of aspiration. Monitor and record bowel
function
 , observe for and reporting diarrhoea or constipation.
 Consider the use of laxatives to prevent faecal impaction.

41.  Hygiene needs: Regular skin care including eye, mouth and
catheter care, as well as care of any invasive sites.
 Psychosocial needs: Ensure all procedures are explained to the
patient to the family members and regarding the patient's
condition and encourage appropriate interaction and involvement
in care.