MANAGEMENT OF UNCONCIOUS PATIENT IN EMERGENCY

Managing an unconscious patient

1. MANAGEMENT OF UNCONSCIOUS PATIENT BY BATUUSA DIANAH NANKINGA TUTOR: DR. NSIIMA 22/03/2024

2. OUTLINE Definition Etiology A pproach Primary survey Secondary survey Treatment and management Prognosis C onclusion

3. Definitions Consciousness; refers to the state of being awake and aware of one’s surroundings. Requires both wakefulness and awareness. Unconsciousness; refers to a state in which the patient is totally unaware of both self and external surroundings, and unable to respond meaningfully to external stimuli. Here a patient lacks both wakefulness and awareness. Syncope/fainting; refers to the brief loss of consciousness from which the patient recovers spontaneously or with slight help . Coma; unarousable unresponsiveness. Deep, prolonged unconsciousness. Also defined as a Glasgow coma scale score of <8 or a score of U on the AVPU scale.

4. Etiology and pathophysiology Unconsciousness is caused by impairment of reticular activating system(ARAS) which is a system of the upper brainstem and the thalamic neurons. This system with its broad connections to the cerebral hemispheres help maintain wakefulness. Alteration in alertness can be caused by Focal lesion directly damaging the ARAS , Damage to the cerebral hemispheres

5. Etiology…

6. A pproach to an unconscious patient DON’T PANIC, call for help . An alteration in arousal represents an acute life threatening emergency Early physiological stability and diagnosis are vital in preservation of life and brain function .

7. Primary Survey : assess, treat and reassess

8. Cont..

9. Circulation – c Pulse Rate Rhythm character Extremities Capillary refill time Blood pressure

10. Brain stem reflexes Cranial nerves Motor responses

11. Exposure =E General exam -cyanosis, anemia, lymphadenopathy, dehydration. Examine the head for Swelling, bruising( racoon eyes, battle sign), lacerations and bleeding. CSF rhinorrhea-skull fracture Neck rigidity- meningitis. Needle tracks-IV drug use Tongue bitten on the side-recent convulsive seizure Temperature

12. Secondary survey (focused history and examination ) Performed after initial assessment after life threatening problems are found and corrected Main purpose is to discover and care for a patient’s specific injuries or medical problems Includes: obtaining patient relevant history Rapid assessment or focused assessment Repeating vital signs

13. Secondary survey… Ample patient history Obtained from bystanders/ family Mnemonic to obtain ample history: S – Signs/ symptoms A – Allergies M – Medications P – relevant past medical history L – Last oral intake E – Events leading to the illness or injury

14. History cont.. Recent illness fever – infection increasing headache- expanding intracranial pressure, venous sinus Thrombosis recent fall-subdural hematoma recent confusion or delirium-metabolic or toxic cause Prescription or non prescription drugs Medical or psychiatric conditions Previous hospital records should be requested urgently and next of kin contacted. Patients personal effects-medical alert bracelet or necklace or card in wallet

15. Examination After the initial ABC assessment, the level of consciousness should be formally measured and documented using the GCS score. A focused neurological examination should be undertaken. Other systemic examinations should also be fully done. The pattern of breathing should be assessed as well as the respiratory rate Kussmaul breathing; deep labored breathing indicative of severe metabolic acidosis Ataxic breathing; groups of quick, shallow inspirations followed by regular or irregular periods of apnea, suggests a lesion in the lower pons. Cheyne-stokes breathing; consists of cycles of deep, faster breathing followed by shallow, slower breathing and moments of apnea Central neurologic hyperventilation; characterized by deep, rapid breaths at a rate of at least 25breaths per minute. Indicates a lesion in the pons or midbrain.

16. Investigations Blood tests; CBC, LFTs, RFTs, electrolytes, blood grouping and crossmatch, cardiac markers(troponin, cytokine kinase), RBS, Blood cultures, MRDT, toxicology screen, arterial blood gases. imaging; CT or MRI of the head. X-ray in chest and abdominal related causes. Ultrasonography in trauma(e-FAST). ECG Others Lumbar puncture CSF analysis EEG in suspected cases of non-convulsive status epilepticus.

17. Treatment and management Management of an unconscious patient requires a multi disciplinary approach and team work. As the ABC assessment is undertaken, other team members should be; Taking blood tests Establishing intravenous access Connecting the patient to a cardiac monitor and oxygen probes Commencing appropriate oxygen therapy if indicated Death will occur soonest if airway and breathing are compromised therefore the need for intubation in patients with a GCS score of <8, those who can not protect their airway, those with an ineffective respiratory drive and poor oxygenation. Intravenous fluid resuscitation as indicated. Manage raised intracranial pressure if suspected. Special treatment depends on the underlying etiology of the unconsciousness. Monitor the patients vital signs plus their urinary output through an inserted catheter.

18. Complications of unconsciousness These can either depend on the underlying cause or duration of the unconscious state. Some of these may include the following; Brain damage: prolonged unconsciousness can lead to brain damage due to lack of oxygen and nutrients to the brain Deep vein thrombosis and pulmonary embolism due to prolonged immobility. Muscle atrophy: due to the disuse phenomenon where lack of movement/disuse of the muslces leads to muscle wasting and weakness. Infections: unconscious patients have an increase of infections. Pressure sores particularly in areas where the body bears weight against a surface for an extended period of time. Decubitus ulcers which can result from the pressure sores Aspiration pneumonia: due to the unconsciousness state and the inability of the person to protect their own airway. Can inhale food, fluid or vomitus leading to aspiration pneumonia. Organ failure: unconsciousness can result in compromised functioning of the vital organs of the body such as the heart, lungs, kidneys etc.

19. Prognosis of an unconscious patient Prognosis depends on a number of factors Non traumatic unconscious patient presenting with a stroke have the highest mortality while those presenting with epilepsy and poisoning have the best prognosis. Patients with a lower GCS score at presentation i.e. of a 3-5, have a significantly higher mortality than those with a higher GCS score(7-10). Patients not responding to initial treatment and who remain unconscious are likely to require critical care admission unless withdrawal of treatment and palliation of symptoms is more appropriate. Early communication with the next of kin, family or appropriate advocate is always necessary. When the prognosis is poor, the discussions will include ceiling of care, consideration of future withdrawal of treatment and cardiopulmonary resuscitation.

20. C onclusion The unconscious patient is challenging in terms of immediate care, diagnosis, specific treatment and predicting prognosis. A systemic and logical approach is required with an emphasis on team work. Appropriate measures to resuscitate, stabilize and support an unconscious patient must be performed rapidly. Decisions such as ceiling of care are required at an early stage in patients with a poor prognosis.

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