UNCONSCIOUSNES
S
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.
POSSIBLE CAUSES
Alcohol Trauma
Epilepsy Infection
Insulin Psychiatric
Overdose Stroke, syncope
Uremia (and other
metabolic causes)
APPROACH
ABC
Immediate management
Examination
History
Investigations
ABC
ABC
A –Open the
B –breathing C –circulation
airway
AIRWAY
-Open, clear, maintain
-If trauma present or no history available,
immediately control C-spine
BREATHING
-Assess presence, adequacy
-High concentration O2 immediately on all
patients with decreased LOC
-Assist if respiratory rate, tidal volume
inadequate
CIRCULATION
Pulses?
Perfusion?
bleeding?
IMMEDIATE MANAGEMENT
Maintain i.v line, oxygen inhalation
Blood sample
Control seizures
HISTORY
Allergies
Medication
Previous medical history (Epilepsy,
Diabetes)
Last meal
Event - What has happened?
EXAMINATION
Examination
•Detailed medical
•Vitals examination
•Neurological assessment
•Skin petechial rash Head, Thorax, Neck
•Injection marks Abdomen, limbs, back
Fundoscopy
Vitals
1.Pulse
Tachycardia
Hypovolemia/haemorrhage
hyperthermia
Intoxication
Bradycardia
Raised intracranial pressure
Heart blocks
2.Temperature
Increased
Sepsis
Meningitis ,encephalitis
Malaria , haemorrhage
Decreased
Hypoglycemia
Hypothermia
Myxedema
Alcohol, barbiturate ,sedative or
phenothiazine intoxication.
3.Blood pressure
Increased
Hypertensive encephalopathy
Cerebral haemorrhage
Raised intracranial pressure
Decreased
Hypovolemia
Myocardial infarction
Intoxication/poisoning
4.Respiratory rate
Increased
Pneumonia
Acidosis (DKA, renal failure)
Pulmonary embolism
Respiratory failure
Decreased
Intoxication/poisoning
Skin petechial rash
Meningococcal meningitis
Endocarditis
Sepsis,thrombotic thrombocytopenic
purpura
Multiple injection
marks
Drug addiction
Acute endocarditis
Hepatitis B /C with encephalopathy
HIV
CONTD.
Neurological assessment;
1)General posture
2)Level of conciousness
CONTD.
1)Posture;
Lack of movements on one side
Intermittent twitching
Multifocal myoclonus
DECORTICATION
DECEREBRATION
CONTD.
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
GLASGOW COMA SCALE
MONITORING LEVEL OF CONSCIOUSNESS (SCORE 3-15)
• 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
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
HEAD, CHECK:
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
THORAX, NECK
Clavicles for bruising and possible
fractures
Sternum
Ribs - fractures and abnormal
breathing
Neck rigidity- Meningitis
ABDOMEN, CHECK:
Rigidity and guarding
Pulsating masses
Bruising
Pelvis fractures or abnormal
movement
Groin for dampness
LIMBS, CHECK:
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
BACK, CHECK:
Scapulae for fractures
Spine for irregularities
FUNDOSCOPY
Raised intracranial pressure
Hypertensive changes
Subarachnoid haemorrhage
Diabetic retinopathy
VITAL SIGNS - MONITOR
Respiratory Rate
Pulse Rate
Blood Glucose Levels
Oxygen Saturations
Temperature
IMMEDIATE INVESTIGATIONS
CBC
Blood ESR
LFTs
Urea and Creatnine
Blood and urine cultures
OTHER INVESTIGATIONS
CRP
ABGs
Toxic screen , drug levels
Lumbar puncture and CXR
CT scan
Management
depends on the
cause
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
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
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.
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.
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.
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.
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.
