Approach to. Contents Clinical Evaluation History Examination Lab Evaluation Management.

Approach to

Contents

Clinical Evaluation History

Examination

Lab Evaluation

Management

Basics

Wakefulness depends on the integrity of both cerebral hemi- spheres and the ascending reticular activating formation of the brain stem.

Cont..

The management of an unconscious patient is never an easy task in clinical practice

The duty of physician is Arrive at diagnosis Predict the eventual outcome

History

i) Onset of coma (abrupt, gradual)

ii) Recent complaints ( headache, depression, focal weakness,

vertigo )

iii) Recent injury

iv) Previous medical illness ( diabetes,uraemia, heart disease )

v) Access to drugs ( sedatives,psychotropic drugs )

Examination

General physical Examination

i) Vital signs

ii) Evidence of trauma

iii) Evidence of acute or chronic system illness

iv) Evidence of drug ingestion ( needle marks alcohol breath )

v) Nuchal rigidity (examine with care)

Neurological Examination

State of consciousness Obtundation; responds-to verbal

stimuli although slow and inappropriate. Stupor; the subject can be aroused

only by vigorous and repeated noxious stimuli.

Coma; unarousable and unresponsive.

Respiratory pattern a ) Hyperventilation - midbrain and upper pons lesion metabolic diseases e.g. hepatic coma, diabetes and generalised

raised intracranial pressure in its early stages.

( b ) Hypoventilation - medullary, upper cervical spinal lesion Drug overdose and later stages of cerebral herniation.

( e ) Cheyne-Stoke respiration – usually diencephalic lesion central transtentorial herniation and obstructive hydrocephalus.

( d ) Ataxic respiration (completely irregular breathing) brain-stem dysfunction of a diffuse nature

Pupillary size and reaction

Medium to dilated symmetrical pupils fixed to light structural disease of the brain stem.

Small symmetrical pupils reactive to light metabolic diseases and drug overdose.

Unequal pupil fixed to light intracranial mass lesion producing 3rd nerve palsy e.g

in unilateral uncal herniation.

Eye movements

Vestibulo-ocular reflexes – douching of one ear with cold water produces ipsi-lateral deviation of both eyes with a contralateral quick phase nystagmus lasting for 1—2 minutes. Use of hot water produces the opposite effect i.e. contralateral deviation with ipsilateral quick phase nystagmus. Bilateral douching with cold water gives rise to downward deviation with upward nystagmus and with hot water the opposite response. Absence or abnormal response indicates brain-stem dysfunction.

Oculo-cephalic reflexes (Doll's eye movement ) - Normal response consist of deviation of both eyes to the opposite direction of head rotation. Again absence or abnormal response indicates brain-stem dysfunction.

Motor Responses

This is elicited by applying peripheral noxious stimuli e.g. pinching of limbs rubbing the sternum to elicit pain.

( a ) Appropriate response – brushing away the source of stimulus.

{ b ) Inappropriate response - decerebrate or decorticate rigidity. Motor response is also of localising value. Paralysed limb will show no response and presence of hemiplegia can therefore be evident. Decerebrate rigidity indicates brain-stem damage and if bilateral is usually associated with a very poor prognosis. Complete flaccidity with no response to noxious stimuli is often indicative of severe central nervous system depression due to drug overdose.

Laboratory Evaluation

Supratentorial lesions

Skull radiograph Computerised tomographic scan

CTscan) Carotid angiography EEG ( electroencephalogram )

Infratentorial lesions

Skull radiograph CT scan Vertebral angiography EEG Ventriculography

Diffuse neuronal lesions Examination of CSF ( cerebro spinal fluid ) Serum glucose, calcium, Na, K, magnesium Blood gases and PH Liver and renal functions Drug levels

Management

Initial Management

Airway Breathing Circulation Deformity Exposure

Definitive Management In general, management of the comatose patient

depends on the cause. However, while the patient is undergoing evaluation, it is essential to :

pressure area care care of the mouth, eyes and skin physiotherapy to protect muscles and joints risks of deep vein thrombosis risks of stress ulceration of the stomach nutrition and fluid balance urinary catheterization monitoring of the CVS infection control maintenance of adequate oxygenation, with the

assistance of artificial ventilation

You are in emergency department when an unconscious patient land in emergency with B.P 90/50 pulse 92/min and attendants tell u that the patient suddenly fell unconscious, how will you approach ?

APPROACH

ABC

Immediate management

Examination

History

Investigations

ABC

ABC

A –Open theairway

B –breathing C –circulation

Immediate management

Maintain i.v line, oxygen inhalation

Blood sample for RBS

Control seizures

Consider i.v glucose, thiamine, naloxone, flumazenil

Examination

Examination

•Vitals•Skin petechial rash

•Injection marks

•Neurological assessment•Neck rigidity•Fundoscopy

•Brainstem reflexes

•Detailed medical examination

CONTD.

Vitals1.Pulse

tachycardia Hypovolemia/haemorrhage hyperthermia Intoxication

bradycardia Raised intracranial pressure Heart blocks

CONTD.

2.Temperature increased Sepsis Meningitis ,encephalitis Malaria ,Pontine haemorrhage

Decreased Hypoglycemia Hypothermia (less than 31 C) Myxedema Alcohol, barbiturate ,sedative or

phenothiazine intoxication.

CONTD.

3.Blood pressureincreased

Hypertensive encephalopathy Cerebral haemorrhage Raised intracranial pressure

Decreased Hypovolemia /hgr Myocardial infarction Intoxication/poisoning Profound hypothyroidism, Addisonian

crisis

CONTD.

4.Respiratory rateIncreased(tachypnae)

Pneumonia Acidosis (DKA, renal failure) Pulmonary embolism Respiratory failure

Decreased Intoxication/poisoning

CONTD.

Skin petechial rash Meningococcal meningitis

Endocarditis

Sepsis,thrombotic thrombocytopenic purpura

Rickettsial infectionRMS (rocky mountain spotted fever)

CONTD.

Multiple injection marks Drug addiction

Acute endocarditis

Hepatitis B /C with encephalopathy

HIV

CONTD.

Neurological assessment;

General posture

Level of conciousness

CONTD.

Posture; Lack of movements on one side

Intermittent twitching

Multifocal myoclonus

DECORTICATION

DECEREBRATION

CONTD.

Level of conciousness Glasgow coma scale (GCS)Best motor response Best verbal responseEye opening GCS score 3 –severe injury less than or equal to 8 –

moderate injury 9 to 12 – minor injury

CONTD.

An abbreviated coma scale is used in the assessment of critically ill patient (primary servey)

AVPUA –alertV – respond to voice stimulusP – respond to painU - unresponsive

Brainstem reflexes

Pupillary responses to light

Spontaneous and elicited eye movements

Corneal responses

Respiratory movements

CONTD.Ocular movements

Conjugate deviation of eyes to a side – ipsilateral hemisphere frontal leison or contralateral pontine leison. Rarely eyes may turn paradoxically away from the side of deep hemisphere leison (WRONG-WAY EYES)

Downward conjugate deviation of eyes – mesencephalic leison.

CONTD.

Eyes turn down and inward in – thalamic hgr and upper midbrain leison.

Ocular bobbing – is diagnostic of pontine hgr.

Ocular dipping - indicates diffuse cortical anoxic damage.

Dysconjugate ocular deviation – brainstem leison.

CONTD.

Oculocephalic reflex (Doll’s eyes response) – brisk in cortical depression ,lost in brainstem leison.

Oculovestibulo responses –two components

1.Conjugate ocular movement – loss in brainstem damage.

2.Nystagmus – loss in damage to cerebral hemisphere

CONTD.Pupillary changes;

Sr no

pupils causes

1 B/L Pin-point pupils ( less than 1mm)but responsive

Opiates poisoning ,extensive pontine hgr.

2 B/L small pupils but responsive

B/L diencephalon involvement or destructive pontine leison

3 B/L slightly small pupils(1 to 2.5 mm) but responsive

Metabolic encephalopathies ,deep B/L hemisphere leison or thalamic hgr.

4 B/L dilated and fixed Severe midbrain damage, Overdose of atropine,scopolamine,glutethemide.

CONTD.

Sr. no.

Pupil cause

6 U/L small pupil Horner syndrome

5 Ipsilateral dilated pupil with no direct or consensual reflexes

Compression of 3rd cranial nerve e.g, uncal herniation

7 U/L small and irregular pupilunresponsive

Leison in pretectal area of midbrain

CONTD.Respiratory movements

Has less localizing value then other brainstem reflexes.

Cheyen-stokes respiration(classic cyclic form ending with a brief apneic period – B/L hemisphere damage or metabolic depression.

Rapid ,deep breathing (Kussmaul) –in metabolic acidosis and in pontomesencephalic leison.

Neck rigidity;

Meningitis

Subarachnoid haemorrhage

Fundoscopy

Raised intracranial pressure

Hypertensive changes

Subarachnoid haemorrhage

Diabetic retinopathy

History

Onset of the symptoms

Antecedent symptoms

Use of medications

Chronic liver ,kidney ,lung or heart disease

CAUSES OF UNCONCIOUSNESS

Braintumor

epilepsy

infectionsCardiovascular

disease

trauma

metabolicdisturbances

Thiaminedeficiency

Causes of unconciousness

Causes of unconciousness

MetabolicDrugs, poisoning e.g CO ,alcoholHypoglcemia, hyperglycemia (keto

acidoti or HONK)Hypoxia, carbondiaoxide narcosis

(COPD)SepticemiaHypothermiaMyxedema ,addisonian crisisHepatic / uremic encephalopathy

CONTD.

NeurologicalTraumaInfections – meningitis, encephalitis,

malaria, typhoid, rabies, trypanosomiasis.

Tumours – cerebral / meningeal tumorsVascular – subdural / subarachnoid hgr,

stroke, hypertensive encephalopathyEpilepsy – nonconvulsive status /

postictal state

Immediate investigations

RBS

Blood CP and ESR

LFTs

Urea and Creatnine

Blood and urine cultures

Other investigations

CRP

ABGs

Toxic screen , drug levels

Lumbar puncture and CXR

CT scan

Summary

ABC of life support

Oxygen and I.V access

Stabilize cervical spine

CONTD.

Blood glucose

Control seizures

Consider I.V glucose, thiamine, naloxone, flumazenil

CONTD.

Brief examination and obtain history

Investigate

Reassess the situation and plan further

Take home message

Early management

Prompt diagnosis

MCQ

Pupillary changes in opiate poisoning

1.B/L pinpoint

2.U/L pin point

3.B/L dilated

Answer

1. B/L pin point

MCQ

Myxoedema coma seen in

1.Euthyroid state

2.Hyperthyroid state

3. hypothyroid state

Answer

3. hypothyroid state

Thank You