Care of unconscious patient

unconscious patient

1. Care of Unconscious patient Presented by: Anjali Arora M.Sc. Nursing -1 ST Year College Of Nursing Institute Of Liver and Biliary Sciences

2. Introduction The concept of “ Time is Brain ” has to be borne in mind, and a work up quick, investigations for the cause of coma, will make a physician’s effort highly successful one. Wide tracking of causes, by repeated patient questioning to the relatives, at the same time, carrying out the emergency measures to recover the patient’s health is imperative.

3. Terminologies

4. Terminologies Consciousness is the state or quality of awareness, or, of being aware of an external object or something within oneself. Awareness means the ability to combine the data in memory to the surrounding internal and external stimuli. When a person is conscious, he or she is awake, responds to his or her surroundings and behaves meaningfully. Unconsciousness is an abnormal state in which a patient is totally unaware of both self and external surroundings, and unable to respond meaningfully to external stimuli Alertness : open eyes spontaneously, responds to stimuli appropriately. Lethargy:  slow to respond but appropriate response; opens eyes to stimuli; oriented. Stupor : aroused by and opens eyes to painful stimuli; never fully awake; confused; unclear conversation. Semi-coma : move in response to painful stimuli; no conversation; protective blinking/swallowing; pupillary reflex present.

5. Terminologies Coma : unresponsive except to severe pain; no protective reflexes; fixed pupils; no voluntary movement. Fainting, also known as Syncope, is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery. Vegetative state- It is a clinical condition of complete unawareness of self and environment with damage to CNS. No chance to recover back. Brain death , wherein the brain function has ceased irreversibly, is the deepest level of unconsciousness. ( Puumalainen 2005.)

6. Difference Between Vegetative State And Brain Death Vegetative State Brain Death

7. Introduction

8. unconsciousness “Unconsciousness means lack of awareness”

9. Definition “Unconsciousness is an abnormal state in which a patient is totally unaware of both self and external surroundings, and unable to respond meaningfully to external stimuli ” It can range from a brief episode of fainting to the prolonged unconsciousness of coma from which the person cannot be aroused, even with vigorous external stimuli .

10. Unconsciousness When someone’s consciousness level decreases his or her state of alertness gradually declines from somnolence to coma.  Lethargy Stuporous Semi-Coma Coma Vegetative state Brain death

11. Case You were called into resuscitation, where a 55 year old man onto the ED stretcher. You were called after his family found him unconscious at home. His current GCS is 3…

12. My Approach The differential diagnosis of altered mental status is huge and can be overwhelming in the face of an acutely ill, undifferentiated emergency department patient. I try to sort through diagnoses based on how quickly they could kill the patient and how quickly I can treat them.

13. What could kill my patient immediately? Cardiac arrest Airway obstruction Breathing (oxygenation) The immediate first step is to check for a pulse. At the same time, nurses are getting the patient on the monitor and getting a full set of vital signs. Next, I assess airway patency and breathing pattern. If necessary,   I start with basic, temporizing airway maneuvers , such as positioning, oral/nasal airways, (I don’t want to intubate a patient who only requires D50W) The need for spine precautions should also be considered. NOTE:  Don’t forget to get the history before they leave. The  patient can’t communicate and the medics almost always have important information.

14. What could kill my patient in the next few minutes? Hypoglycemia Overdose Intracranial hypertension and herniation My first priority is getting the glucose checked, primarily so it does not get overlooked. Next, I ask my nurses to start working on vascular access while I perform a rapid, focused primary survey: Neuro:  Pupils, eye movements, corneal reflex, moving all 4 extremities, reflexes, muscle tone, any asymmetry? Signs of impending herniation:  Hypertension, bradycardia, and irregular respirations Breathing pattern:  Regular, Cheyne-Stokes, irregular, apnea?

15. Cont… Signs of shock:  Cap refill, skin warm or cold? Abdo:  Any obvious pain or masses? Trauma:  Any clear signs of trauma? This all takes about 1 minute to complete. At this point, I am ready to consider if any immediate therapeutic interventions are required: Hypoglycemia:  D50W 1-2 amps IV Opioid toxidrome (or suspicion):  Naloxone 0.2-0.4mg IV q2-3min. (If the patient is stable, I will usually start with a much lower dose (0.04mg IV) to avoid precipitating rapid opioid withdrawal.) Intubate; provide analgesia and sedation; elevated the head of the bed; respirate to a target pCO2 of 35mmHg; Mannitol 0.5-1gram IV or 3% hypertonic saline 2-3ml/kg IV bolus.

16. What could kill my patient in the next 10 minutes? Still the ABCs Hypotension Anaphylaxis Hyperkalemia MI It’s easy to get lost in the differential. After the rapid primary survey and initial interventions. I remind myself to reassess the ABCs. If a rapidly reversible cause hasn’t been identified. I will start planning for a definitive airway. The next two diagnostic moves are an ECG and the ultrasound machine.

17. Cont…. The ECG will provide essential diagnostic information about ischemia, arrhythmias, overdoses, and hyperkalemia. Ultrasound examination may be a  RUSH exam for hypotension, or a more focal exam based depending on the findings of the primary survey. Interventions at this point:  For hypotension, I will start a fluid bolus or blood products depending on the context. If there is any suspicion of anaphylaxis, I will give epinephrine 0.5mg IM.   If there is reason to suspect hyperkalemia, or any bizarre appearing ECG, I will empirically give calcium (2-3 amps of calcium gluconate IV). 

18. What could kill my patient over the next few hours? Sepsis Intracranial hemorrhage Alcohol Withdrawal Status epilepticus (presumably non-convulsive if I didn’t recognize it immediately Metabolic problems (DKA, HHNK, hyponatremia, thyroid disorders, adrenal disorders)

19. Cont.. After the rapid assessment and management of immediate life threats, the next step is to ensure the patient is adequately resuscitated before the inevitable trip to the CT scanner. A definitive airway should be in place before traveling to radiology. Any signs of shock are addressed with fluids, blood, and/or vasopressors. Blood work, probably already drawn reflexively by the nurses, should be sent off. Unless there is a clear alternative diagnosis, I start empiric antibiotics on everyone. (Acyclovir can also be considered for herpes encephalitis. It is important to use all possible sources of information, including old charts, family, friends, and I also specifically search for things like medic-alert bracelets, medication lists. it is generally better to get therapy started empirically, and Finally, once the patient is stabilized, I will get them to the CT scanner for images of their brain (and any other organs indicated by the primary survey).

20. Causes of unconsciousness Brain-derived causes Brain injury Cerebral hemorrhage Cerebral infarction Brain tumor Central nervous system infections Status epilepticus

21. Causes of unconsciousness Systemic causes Metabolic causes (e.g. ketoacidosis, electrolyte imbalance) Cardiovascular causes (e.g. cardiac arrest, arrhythmia, shock) Hypoxic-ischemic (e.g. drowning, choking) Severe infections (e.g. sepsis) Pulmonary diseases (e.g. aspiration, foreign object in respiratory tract) Intoxication (e.g. carbon monoxide, medicines, ethanol, cyanide) Medicine disadvantage (e.g. opioids, antipsychotics)

22. Causes of unconsciousness COMMON CAUSE-I Interruption of energy substrate delivery Hypoxia Ischemia Hypoglycemia Alteration of neurophysiologic responses of neuronal membranes Drug intoxication Alcohol intoxication Epilepsy

23. Causes of unconsciousness COMMON CAUSE-II Abnormalities of osmolarity Diabetic ketoacidosis Nonketotic hyperosmolar state Hyponatremia Hepatic encephalopathy Hypertensive encephalopathy Uremic encephalopathy

24. Causes of unconsciousness COMMON CAUSE-III Hypercapnia Hypothyroidism Hypothermia Hyperthermia

25. Myxedema Coma: A New Look into an Old Crisis Journal of Thyroid Research   The term myxedema coma is a misnomer, and myxedema crisis may be an apt term as quite a few patients are obtunded, rather than frankly comatose. As the disease is rare and unrecognized, we only have a few isolated case reports and case series, and there is a dearth of randomized controlled trials in the field of myxedema crisis.  Myxedema (crisis) coma is a loss of brain function as a result of severe, longstanding low level of thyroid hormone in the blood (hypothyroidism). Myxedema com is considered a rare life-threatening complication of hypothyroidism, and represents one of the more serious side of of  thyroid disease.

26. Causes of unconsciousness

27. Clinical Manifestations Alterations in LOC occur along a continuum, and the manifestations depend on where the patient is on this continuum. As the patient's state of alertness and consciousness decreases, changes occur in the pupillary response, eye opening response, verbal response, and motor response. However initial alterations in LOC may be reflected by subtle behavioural changes, such as restlessness or increased anxiety. The pupils, normally round and quickly reactive to light, become sluggish (response is slower); as the patient becomes comatose, the pupils become fixed (no response to light). The patient in a coma does not open the eyes, respond verbally, or move the extremities in response to a request to do so.

28. Pathophysiology RAS - Anatomically located in Paramedian tegmental zone of dorsal midbrain-responsible for arousal and cortical activation Cerebral cortex-contains cognition centres determine content of consciousness Impairment to cerebral cortex or brainstem can independently cause Coma: vulnerable to Metabolic disturbances, toxins, Mechanical Injury RAS is impaired, cerebral cortex cannot be aroused.

29. Assessment History Taking Physical Examination After the initial ABC  assessment , the level of consciousness should be formally measured and documented using the Glasgow Coma scale.

30. History

31. General Examination

32. Neuro Examination

33. Oculocephalic (doll’s Eye) Response

34. Oculovestibular (calorie testing ) Response

35. Glasgow coma scale

36. Glasgow coma scale

37. Glasgow coma scale

38. Glasgow coma scale

39. Pupillary Reaction

40. Pupillary Reaction

41. Diagnostic findings Common diagnostic procedures Computed tomography (CT) scanning, Magnetic resonance imaging (MRI), Electroencephalography (EEG). Less common procedures include Positron emission tomography (PET) Single photon Emission computed tomography (SPECT) Laboratory tests include Analysis of blood glucose Electrolytes, serum ammonia, and liver function tests: blood urea nitrogen (BUN) levels; serum Osmolality: calcium level; and partial thromboplastin and prothrombin time. Other studies may be used to evaluate serum ketones, alcohol and drug concentrations, and arterial blood gases.

42. Emergent Management Initial assessment of the unconscious patient is done by utilizing the ABCDE-protocol.

43. Assessment

44. Airway Management

45. Modified Mallampatti Score

46. Breathing

47. Circulation

48. Medical Management The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated, or a tracheostomy may be performed. Until the ability of the patient to breathe is determined, a mechanical ventilator is used to maintain adequate oxygenation and ventilation. The circulatory status (blood-pressure, heart rate) is monitored to ensure adequate perfusion to the body and brain. An intravenous (IV) catheter is inserted to provide access for IV fluids and medications. Neurologic care focuses on the specific neurological pathology, if known. Nutritional support, via a feeding tube or a gastrostomy tube, is initiated as soon as possible. In addition to measures designed to determine and treat the underlying causes of altered LOC, other medical interventions are aimed at pharmacologic management and prevention of complications.

49. Non-Invasive Hemodynamic monitoring

50. Invasive Hemodynamic monitoring

51. Resuscitation trolley

52. List of Emergency Drugs

53. Drug Calculation

54. Nursing Management of Unconscious Patient

55. Nursing Management Ineffective airway clearance related to inability to clear respiratory secretions as evidenced by unclear lung sounds, unequal lung expansion, noisy respiration, presence of stridor, cyanosis or pallor Ineffective cerebral tissue perfusion related to effects of increased ICP as evidenced by papilledema, vomiting. Imbalanced nutrition – less than body temperature, related to inability to eat and swallow as evidenced by weight and other nutritional parameters less than normal.

56. Nursing Management Altered oral mucous membrane related to ET insertion, absence of pharyngeal reflex, inability to ingest fluid as evidenced by dryness, inflammation, crusting and halitosis. Self-care deficit- bathing, feeding, grooming, toileting related to unconscious state as evidenced by unkempt and poorly nourished look, bed soiling. Ineffective thermoregulation related to damage to hypothalamic centre as evidenced by persistent elevation of body temperature, warm and dry skin, flushed appearance of skin.

57. Nursing Management Risk for complications – pressure sore, contractures, DVT, hypostatic pneumonia, constipation – related to immobility. Risk of injury related to unconscious state. Risk for fluid volume deficit related to inability to ingest fluids, dehydration from osmotic diuretics. Interrupted family process related to chronic illness of a family member as evidenced by anger, grief, non-participation in client care.

58. Nursing Documentation

59. Points to remember Put air way if Pt. is unconscious. Tracheostomy – if air way obstruction. Suction equipment available. Assess breath sound 1-2 hourly. Never give fluid / food to shallow. Lateral position. Perineal care. Examine abdomen for distention. Involve family in care (general wards).

60. Complications Skin: - Pressure sore, laceration. Respiratory: - pneumonia, pulmonary Embolism. C.V. system : - DVT, postural hypotension, thromboembolism. G.I. system : - Paralytic ileus, constipation, distention. Urological: - UTI Musculoskeletal: - Contracture, dystrophy, weakness. Neurological: - Foot drop. Psychological: - Anxiety, depression.

61. Research article Continuous EEG Monitoring Predicts a Clinically Meaningful Recovery Among Adult Inpatients. Continuous EEG findings can be used to prognosticate survival and functional recovery, and provide guidance in establishing goals of care.

62. Research article Hidden brain activity revealed in people with coma Hospital patients who appear unresponsive after commands show evidence of brain activity. Fifteen per cent of hospital patients with severe brain injuries exhibited cognitive activity in response to commands — even though they did not react visibly. Jan Claassen at Columbia University in New York and his colleagues studied 104 ‘clinically unresponsive’ patients whose brains had been damaged by a stroke or other trauma. None showed a visible response to verbal instructions ; some were in a coma. The researchers used a technique called electroencephalography (EEG) to study electrical activity in the patients’ brains. When asked to move one hand, 15% of patients showed brain patterns similar to those of healthy volunteers responding to the same instructions . A year after their injury, 44% of patients whose brains responded to commands could look after themselves for at least 8 hours, compared with only 14% of those whose brains did not respond. Larger trials are needed to test the value of EEG for prognosis, the authors say.

63. Summary

64. Conclusion “ Time is Brain ” , an earliest intervention will save the patient’s brain and life, to a great extent .