APPROACH TO AN

UNCONSCIOUS PATIENT

BY
ADEYANJU OYEYEMI
 OUTLINE
 INTRODUCTION
 PATHOPHYSIOLOGY
 AETIOLOGY
 CLINICAL APPROACH
 HISTORY TAKING
 EXAMINATION
 INVESTIGATIONS
 TREATMENT /MANAGEMENT
 PROGNOSIS
 COMPLICATION
 PATIENT EDUCATION
 CONCLUSION
 REFERENCE
 INTRODUCTION

• CONSCIOUSNESS: is a state of full awareness of the self and one’s relationship to

the environment.
• IMPAIRED CONSCIOUSNESS: can be defined as reduced alertness, the ability to
be aroused, or awareness of oneself and the environment.
• UNCONSCIOUSNESS: It is an alteration of mental state that involves complete or
near-complete lack of responsiveness to people and other environmental stimuli
• COMA: Coma is a state of unresponsiveness in which the patient lies with eyes closed
and cannot be aroused to respond appropriately to stimuli even with vigorous
stimulation.
• Coma has also been defined objectively as a Glasgow coma scale (GCS) less than 8.
• CONFUSION: This is an impairment of content of consciousness — i.e attention & concentration,
thought and memory, resulting in an inability to process information with normal speed & clarity. It is
associated with distractibility & disorientation and lack of recognition.

• STUPOR: is a condition of deep sleep or similar behavioural unresponsiveness from which the
subject can be aroused with vigorous and continuous stimulation.
• Some patients will regain full consciousness without intervention, while others will require
intensive management and intricate diagnostic testing.
• During unconsciousness, the patient losses all protective reflexes and sensation responses and is
prone to aspiration and skin ulcers.
 PATHOGENESIS

 THE RETICULAR ACTIVATING SYSTEM

 Network of nuclei & interconnecting fibres occupy the grey matter, core of pons, midbrain
& post diencephalon
 This network provides the anatomical and physiological basis for wakeful
consciousness
 Fibres from the formation are also vital in controlling respiration, cardiac rhythms, acoustic
process and other essential functions such as swallowing
 Interruption anywhere along this pathway, either structural or metabolic, results in loss
of consciousness.
 Any disturbance in this normal functioning results in the transition from alert to
comatose state
• It could involve neuronal dysfunction from a decrease in
the supply of glucose or oxygen to the brain.
• Structural lesions of the central nervous system may lead
to coma from direct destruction of arousal areas of the
brain or from secondary damage from shifting of
intracranial structures, vascular compression, or increased
intracranial pressure.
 AETIOLOGY

• Unconsciousness is generally caused by a temporary or

permanent impairment of either the reticular activating system in
the brainstem, both cerebral hemispheres, or bilateral thalamus.
 The main mechanisms are:
• Neurological/Structural brain lesions.
• Metabolic conditions.
• Diffused physiological brain dysfunction.
• psychiatric causes.
 CLINICAL APPROACH
 INITIAL ASSESSMENT
 When you are reviewing an unconscious patient, a rapid assessment
should replace the usual systematic history taking and physical
examination in order to identify abnormal physiology quickly and to
administer immediate life-saving interventions to prevent further
deterioration and death.
 The four core components of care; history, examination, investigation and
treatment/management should occur in parallel.
 A systematic and structured ABCDE (airway, breathing, circulation,
disability, exposure) approach should be employed by teams caring for
unconscious patients. Supportive care and specific treatments must not be
delayed.
 ABCDE
 The ABCDE approach provides a standardised framework for simultaneously
assessing and treating life-threatening problems in critically ill patients. This
systematic approach will help break down complex and stressful clinical
situations into more manageable components. It stands for
• Airway and cervical spine control
• Breathing and ventilation
• Circulation
• Disability: Neurological status
• Exposure/Environmental control
• Note: It is always safe to start with ABCDE (except when you witness
cardiac arrest).
 AIRWAY AND CERVICAL SPINE
CONTROL
 In the unconscious patient, the priority is airway management, to avoid a preventable
cause of hypoxia.
 Common problems with the airway of patient with a seriously reduced level of
consciousness involve blockage of the pharynx by the tongue, a foreign body, or vomit.
ASSESSMENT:
• Assess patency of airway and imminent threats e.g. Mucosal damage, anaphylaxis
• Open the airway with a chin lift or jaw thrust
• Check for upper airway obstruction – foreign bodies, dislodged teeth, dentures,
macroglossia etc.
• Look for facial fractures and injuries to the neck (trachea and larynx).
• Listen for abnormal breathing sounds, stridor or hoarseness.
 MANAGEMENT
 Protect cervical spine in any suspected trauma associated cases, before attempting
any interventions
 Remove foreign body by direct vision and suctioning (removing excess secretions
from the nasal cavity, mouth, throat and trachea).
 An airway adjunct may be required to maintain patency eg nasopharyngeal airway
(in the conscious patient) or an oropharyngeal airway (in the unconscious patient)
 Administer high concentrations of inspired oxygen using the appropriate face mask
for patient and monitor oxygen saturation
 Intubate immediately for patients with smoke inhalation, burn,
severe anaphylactic reaction, trauma (GCS <8 or any spinal injuries).
BREATHING

 In the unconscious patient, after the airway is opened the

next area to assess is the patient's breathing,primarily to
find if the patient is making normal respiratory efforts.
 It is vital to identify and treat hypoxia, as it can lead
rapidly to cardiac arrest and death. Perform a thorough
assessment, looking for life-threatening respiratory
compromise due to conditions such as acute severe
asthma, pulmonary oedema or tension pneumothorax.
 MANAGEMENT
• Determine centrality of the trachea and apex beat
• Look for symmetrical expansion and respiratory rate.
• Attach a pulse oximeter to assess peripheral oxygenation. Be alert to
circumstances in which this measurement may be unreliable.
• Look for obvious contusion, laceration or flail segments.
• Listen for movements of air: normal, absent or decreased
• Recognise specific life-threatening conditions eg: Tension pneumothorax,
Flail chest with pulmonary contusion, Life-threatening bronchospasm,
Pulmonary oedema.
 RATE: Normal rate in adults is 12-20 per minute. Above 30 indicates distress
 AIR ENTRY: Look and feel for bilateral chest rise; listen for bilateral air entry.
 COLOUR: Assess for cyanosis. Also assess for pallor.
 EFFORT: Increased respiratory efforts means the patient is in distress.
 Oxygen saturation: Normal SpO2 is 95% - 100%
 Give oxygen when the SpO2 is below 95%
 Treatment of specific disease entities.
 Definitive air-way and assisted ventilation if necessary
 Acidotic breathing (Kussmaul’s); agonal breathing (gasping); apnoeistic breathing
(rapid irregular gasping); Cheyne Stokes (erratic breathing due to poor
brainstem perfusion)
 CIRCULATION
 Once oxygen can be delivered to the lungs by a clear airway and efficient
breathing, there needs to be a circulation to deliver it to the rest of the body.
 Examination sequence
 • Look at and feel the skin; a patient in shock will be cold with pale, white or
mottled skin.
 Check capillary refill by pressing on a fingertip (held at the level of the heart)
for 5 seconds. This will cause it to blanch. When the pressure is released the
colour should return to the fingertip in less than 2 seconds. If the capillary refill
time is delayed, this indicates poor peripheral perfusion or shock.
 • Assess the pulse rate and rhythm. A heart rate of less than 60 beats per minute
(bpm) or more than 100 bpm requires further investigation. A heart rate of more
than 130 bpm requires immediate attention.
 Palpate peripheral and central pulses, assessing the volume and character ; poorly
felt peripheral pulses may indicate hypovolaemia or poor cardiac output, whereas a
bounding pulse may indicate sepsis. As blood pressure falls, peripheral pulses
diminish, with loss of the radial, then femoral and finally carotid pulsation.
 Attach an ECG monitor to the patient to assess heart rate and rhythm.
• Check the blood pressure. Use a manual sphygmomanometer, as automated blood
pressure devices may be inaccurate in the acutely unwell patient.
• Examine the jugular venous pressure.
• Identify the position of the apex beat and auscultate the heart to identify added
sounds or murmurs
 IV access with administration IV crystalloid solution
 Draw blood for base line lab investigations, grouping and cross matching.
 Blood transfusion if indicated
 Prevent hypothermia
 DISABILITY
 This is the Neurological exam
 The aim is to detect life threatening neurological conditions
 1. Check the patient’s pupillary response
 2. Assess the posture
 •Lateralizing signs/lack of movements on one side/tone-power-reflexes
 •Abnormal posturing and movements: intermittent twitching, decortication,
decerebration
 3. Assess the Glasgow Coma Scale (GCS)/AVPU
 •A Alert
 •V Responsive to verbal stimuli
 •P Responsive only to painful stimuli
 •U Unresponsive
 4. Check for any signs of raised intracranial pressure
 •Cushing’s triad (HTN, bradycardia, shallow and irregular respiration)
 5. Assess breathing pattern
 •Acidotic breathing (Kussmaul’s); agonal breathing (gasping); apnoeistic
breathing (rapid irregular gasping); Cheyne Stokes (erratic breathing due to
poor brainstem perfusion)
 1.Abort and treat any seizures
 2.Don’t ever forget to check Glucose
 50ml 50%dextrose if hypoglycaemic if HGT <3.5mmol/L
 The Glasgow coma scale
 •It is a Neurological scale, aims to give a reliable, objective way of
recording the conscious state of a person, for initial as well as continuing
assessment
 •Initially used to assess LOC after head injury, now used in acute medical
 and trauma patients and in chronic patient monitoring
 •Published in 1974 by Graham Teasdale and Bryan J Jennet, professors
of neurosurgery the university of Glasgow's institute of neurological sciences at
the city's southern general hospital.
 •The pair went on to author the textbook Management Of Head Injuries
 •The GCS measures Eye Opening (E); Best Motor Response (M); and
 Best Verbal Response (V)
 ASSESSMENT
 •GCS: 14-15 (Mild head injury)
 •GCS: 9-13 (Moderate head injury)
 •GCS: 3-8 (Severe head injury)

 GCS: 14-15 (MILD HEAD INJURY)

 •Patient awake, may be orientated
 •History obtainable include name, age, time of injury, LOC, amnesia,
headaches, seizures
 •Examination – systemic injuries may be present, eg spine & facial bones, do
neurological exam
 •Specific investigations – C-spine & other XR as required, blood tests: eg toxic screen.
CT ideal in all patients, except completely asymptomatic & neurologically
intact patients
 GCS: 9-13 (MODERATE HEAD INJURY)
 •Patient may be confused or sleepy, but still able to follow simple
commands
 •Initial exam & blood tests as above
 •CT scan should be done in all cases
 •If patient is to be transported, consider intubation

 GCS: 3-8 (SEVERE HEAD INJURY)

 •Intubate
 EXPOSURE/ENVIRONMENTAL CONTROL
 Examine the patient thoroughly while respecting their dignity and minimising heat loss.
 Examination sequence
 The aim is to expose the patient so that an adequate complete examination can be performed
 Look for evidence of trauma, blood loss and rashes, in particular the non-blanching petechial rash
of meningococcal bacteraemia.
 Check the temperature using an infrared tympanic thermometer. Normal mean body temperature is
36.5°C. •A temperature below 35°C indicates hypothermia and should be confirmed by measuring a
core (rectal) temperature, and treated by external re-warming using a warming system such as a
Bair Hugger.
 •A temperature above 37.8°C indicates fever and, if acute, should prompt a search for infection
and/or sepsis.
 Swellings and bruises
 Remember to turn patient on back to examine for injuries to back (log role C-spine patient)
 HISTORY TAKING
 Since the patient is unconscious, a full and precise history cannot be gotten. A
brief history can be obtained from the relatives around or witnesses of the
event and also from paramedics.
 The following history if gotten may be helpful
• A – Allergies
• M – Medications/Mechanism (eg. Trauma)
• P – Past Medical History/Past Illnesses
• L – Last meal
• E – Events leading to incident
 A full history will be taken when the unconscious state is reversed and the
patient becomes conscious.
SYMPTOMS THAT COULD BE ASSOCIATED WITH
UNCONSCIOUSNESS

 Seizures
 Loss of bowel or bladder function
 Falling
 Sweating
 Fever etc
 EXAMINATION
 Top to toe and systematic approach signs of cirrhosis, neck rigidity –
bacterial meningitis, subarachnoid heamorrhage
 Don’t forget skin – open wounds, petechial rashes, bruising
 Always remember to check the patient’s back
 RE-ASSESSMENT
 Monitor condition of patient and check for any signs of deterioration.
Assess the effect of treatment given.
 If any evidence suggests deterioration –return to ‘A’ in ABCDE and
repeat the process because you may have missed something
 Monitoring
 1.Pulse Oximetry
 2.Respiratory Rate
 3.Blood Pressure
 4.12 Lead ECG Monitoring
 5.Chest X-ray
 6.Temperature
 7.Arterial blood gases
 8.Glasgow Coma Scale
 9.Urinary Catheter (Urinary Output); Nasogastric Tube If Indicated
 10.Capnography – If Intubated And Ventilated
 Investigations
 Investigations aid diagnosis, assessment of severity and monitoring of ongoing
care. Before considering any further investigations, a bedside capillary blood
glucose must be performed to exclude hypoglycaemia.
 Urgent imaging of the brain is important and a structural pathology should
always be considered if the cause of unconsciousness is not obvious from the
initial rapid assessment.
 Computed tomography (CT) of the brain is the investigation of choice to
exclude common pathologies such as intracranial bleed, stroke or space-
occupying lesions. If the CT brain scan is normal and the diagnosis remains
unclear, further imaging with a magnetic resonance scan may be required.
 If there is no contraindication, a lumbar puncture should be considered when
the cause of unconsciousness remains unclear or a central nervous system
infection is suspected.
 Electroencephalography (EEG) should be performed in suspected
cases of non-convulsive status epilepticus. In this condition there is
prolonged seizure activity but in the absence of motor signs. It is
more common in older patients. Clinically, patients appear to stare
into space with nystagmus-like eye movements, lip smacking or
myoclonic jerks.
 Treatment and Management
 Because the etiology of unconsciousness is often initially unclear, initial treatment occurs before full evaluation
or diagnostics. Principles of initial management of unconscious patients:
• Ensure oxygenation
• Maintain circulation
• Control glucose
• Reduce intracranial pressure
• Stop seizures
• Treat infection
• Restore acid-base balance and electrolyte balance
• Adjust body temperature
• Administer thiamine
• Consider specific antidotes (naloxone, flumazenil)
• Control agitation
Prognosis

 The prognosis of an unconscious patient is variable and highly

dependent on the etiology, the severity of brain injury, and
individual patient factors. The GCS is used to evaluate outcomes
for research purposes.
 Complications
• Brain damage
• Secondary brain injury from anoxia
• Coma
• Aspiration pneumonia
• Bladder bowel dysfunction
• Skin ulcers
PATIENT EDUCATION

 Prevention is preferable to late interventions. Patients need to be

educated about their systemic illnesses and how to prevent
complications. Some conditions leading to unconsciousness may
allow interventions prior to the development of a coma. Closer
monitoring and education of patients with poorly controlled diabetes
might be an opportunity for prevention. For those patients at risk for
drug overdoses or illicit drug use intoxication, early intervention
and counseling will prevent many complications.
 CONCLUSION
 The unconscious patient is challenging, in terms of immediate care,
diagnosis, specific treatment and predicting prognosis. A systematic
and logical approach is required, with an emphasis on teamwork.
Appropriate measures to resuscitate, stabilise and support an
unconscious patient must be performed rapidly. Unless the cause of
coma is immediately obvious and reversible, input from senior
physicians and critical care colleagues is necessary. Decisions, such as
ceiling of care, are required at an early stage in patients with a poor
prognosis.
REFERENCE

• Davidsons Principles and Practice of Medicine

• Macleod’s Clinical Examination
• https://www.ncbi.nlm.nih.gov/books/NBK538529
• Browse's Introduction to the Symptoms & Signs of Surgical Disease
• https://www.researchgate.net/publication/323008043
• The Diagnosis of stupor and Coma by Fred Plum and Jerome B.
Posner
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