An approach to an unconscious patient

Posted: May 23, 2012 by kiamseong in Medicine

State of awareness can be assessed by GCS score

  • 15 conscious
  • 14-8 impaired/delirious
  • 3-8 unarousable

According to severity of injury:
*Minor injury score 13-15
*Moderate score 9 -12
*Severe injury ≤ 8

E4- spontaneous opening
3 open on speech/call
2 open on pain
1 not open

V5- oriented speech
4 confused
3 inappropriate
2 incomprehensible
1 none

M6 – obey command
5 localised pain
4 withdrawal to pain
3 decorticate (abnormal flexion of limb)
2 decerebrate (abnormal extension of limb)
1 not responding

Causes

  1. Bilateral cortical diseases/processes
    1. Trauma – head injury
    2. Hypoxia – HIE, sinus thrombosis, CVA
    3. Infection – cerebral abscess, meningitis, encephalitis
    4. Haemorrhage – SAH, SDH
    5. Metabolic – DKA, HHS, hypo or hyper Na/K, hypoglycaemia
    6. Organ failure – liver or renal
    7. Postictal
    8. Endocrine – thyroid storm, myxoedema, Addison crisis
    9. Drugs – opiates, alcohol, opioid, alcohol, cocaine, benzodiazepine, antidepressant
  2. Brainstem disorder ~ Supratentoral/infratentoral lesions à SDH, EDH, ICB

Approach

Priority should be given to ABC resuscitation and perform examination simultaneously, then: –

  1. Obtain quick history from witness
    1. Onset – abrupt/gradual
      i.      Acute (sec/min)– CVA, cardiac arrest, SDH, head injury
      ii.      Subacute (min-hrs) – sepsis, infections, drug, hypo
      iii.      Protracted

2.      Recent complaints – headache, depress, weakness, vertigo
3.     Recent injury
4.     Previous medical illness

2. Examination

  1. Vitals – T, PR, BP, RR
  2. Skin petechial rashes, ecchymosis (meningoencephalitis)
  3. Neurological assessment
    i.      Posture
    * Lack of movement of one side
    * Intermittent twitching
    * Multifocal myoclonus
    * Decortication
    * decerebration

ii.      Level of consciousness
iii.      Neck rigidity
iv.      Pupil sizes – Horner Syndrome (ptosis, myosis, anhydrosis and enophthalmus), atropine overdose, opioid poisoning, ICB etc
v.      Funduscopy
vi.      Brainstem reflex – pupil reflexes
vii.      Corneal reflex
viii.      Doll’s eye reflex (eye move to opposite side of movement so it always goes to centre) – if negative à brainstem injured

4. Racoon eyes ~ basal skull #
5. Otorrhoea/rhinorrhoea
6. Nails, dxt marks
7. Breathing
i.      Cheyne-Stroke – rapid, shallow with periodic apnoeic episodes à heart failure, strokes, traumatic brain injuries, tumours, CO poisoning, morphine, toxic metabolic encephalopathy
ii.      Kussmaul – deep laboured breathing (usually met acidosis) e.g. DKA, renal failure
iii.      Biot breathing – cluster pattern ~ pontine malfunction
iv.      Gasping – severe hypoxia
3. Ix

ü  FBCü  RBS

ü  ESR/CRP

ü  LFT/RP

ü  Blood C+S

ü  ECG/CXR

ü  Urine toxicologyü  ABG/VBG/Lactate

ü  KIV LP

ü  Serum toxicology

ü  CT Brain

ü  Skull Xray etc

4. Immediate Mx

  • Maintain IV line, O2 therapy
  • Blood sample for RBS
  • Control seizures
  • Consider IV glucose, thiamine, naloxone, flumazenil

5. Further Mx

Depending on the Hx and examination findings, TFT, carboxyHb levels, BFMP and plasma osmolarity (increased in methanol, ethylene glycol and isopropyl alcohol) may be required.
6. Definitive Mx – 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 if necessary

Algorithm

ABC of life support

Oxygen and I.V access

Stabilize cervical spine

Blood glucose

Control seizures

Consider I.V glucose, thiamine, naloxone, flumazenil

Brief examination and obtain history

Investigate

Reassess the situation and plan further

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s