The Unconscious Patient

Management of an unconscious patient, Glasgow coma scale measurement and implications, primary and secondary surveys

1. Department Family Medicine Dora Nginza Hospital Kemi Dele-Ijagbulu, M,B,Ch.B The Unconscious Patient, Cardiopulmonary Resuscitation And Other Topics..

2. The Unconscious Patient, Paediatrics Resuscitation And Other Topics Kemi dele-ijagbulu; M.B.Ch.B

3. OUTLINE APPROACH TO THE UNCONSCIOUS PATIENT MEASURING GCS IN THE ADULT AND THE CHILD APPROACH TO SUDDEN DEATH QUIZ references

4. THE UNCONSCIOUS PATIENT

5. DEFINITIONS Consciousness: The awareness of self and the environment. It requires intact cognitive functions and arousal mechanisms It depends on an intact ascending reticular activating system, contained within the midbrain and brainstem, and an intact cerebral cortex. Interruption anywhere along this pathway, either structural or metabolic, results in loss of consciousness. Any disturbance in this normal functioning results in the transition from alert to comatose state

6. DEFINITIONS Confusion: This is an impairment of content of consciousness — i.E attention & concentration, thought and memory, resulting in an inability to process information with normal speed & clarity. It is associated with distractibility & disorientation and lack of recognition. Stupor: A significant reduction of the level of consciousness in which the subject can be roused only by vigorous and repeated noxious stimuli Unconsciousness : It is a dramatic alteration of mental state that involves complete or near-complete lack of responsiveness to people and other environmental stimuli Coma: Patient is unarousable, unresponsive, and demonstrates primitive reflexes

7. Normal Alert State The Reticular Activating System Network of nuclei & interconnecting fibres, occupies grey matter core of pons, midbrain & post diencephalon Provides the anatomical and physiological basis for wakeful consciousness Fibres from the formation are also vital in controlling respiration, cardiac rhythms, acoustic process and other essential functions such as swallowing Any disturbance in this normal functioning results in the transition from alert to comatose state

8. CAUSES OF UNCONSCIOUSNESS Neurological: Trauma: Head injuries - SAH, ICH, Concussion Infections: Meningitis, Encephalitis – HSV, Cerebral Malaria, Typhoid, Rabies Tumour: Primary, Metastatic Vascular: CVA, Brainstem Infarct, Subdural/Subarachnoid Encephalopathy Epilepsy: Non-occlusive Status, Post-ictal Status

9. CAUSES OF UNCONSCIOUSNESS cont. Non-Neurological/Metabolic: Drugs: Drug Overdose – TCA, EtOH intoxication , Poisoning: CO System failure: Respiratory, CVS, Liver, Renal Respiratory: Hypoxia CO2 narcosis – COPD Infectious: Septicaemia Hypothermia Endocrine: DM related – DKA, HONK , Hypoglycaemia, Myxoedema, Addison’s Crisis, Hepatic Encephalopathy,, Uremic Encephalopathy

10. PRIMARY SURVEY ……..IN PATIENTS WITHOUT CARDIOPULMONARY COLLAPSE

11. PRIMARY SURVEY IMMEDIATE MAMAGEMENT Hello, Hazard, Help... ABCDE A Airway with cervical spine control B Breathing And Ventilation C Circulation D Disability: Neurological Status E Exposure/ Environmental Control Note: it is always safe to start with the alphabet ABCDE (except in witnessed cardiac arrest).

12. AIRWAY Assessment: Assess patency of airway and imminent threats e.g. Mucosal damage, anaphylaxis Assess by talking to patient. Appropriate response suggests clear airway Open the airway with a chin lift or jaw thrust Check for upper airway obstruction – foreign bodies, dislodged teeth, dentures, macroglossia etc. Look for facial fractures and injuries to the neck (trachea and larynx). Listen for abnormal breathing sounds, stridor or hoarseness. Feel for the movement of air Appreciate the potential for cervical spine injury

13. AIRWAY cont. MANAGEMENT Protect c-spine in any suspected trauma associated cases, before attempting any interventions Remove foreign body by direct vision and suction secretion An airway adjunct may be required to maintain patency eg nasopharyngeal airway (in the conscious patient) or an oropharyngeal airway (in the unconscious) Administer high concentrations of inspired oxygen using the appropriate face mask for patient and monitor oxygen saturation Intubate immediately: patients with inhalation burn Severe anaphylaxis reactions Trauma (GCS <8 or any spinal injuries )

14. BREATHING Determine centrality of the trachea and apex beat Look for symmetrical expansion and respiratory rate. Look for obvious contusion, laceration or flail segments. Listen for movements of air: normal, absent or decreased Listen for heart sounds: normal or muffled Recognise specific life-threatening conditions eg: Tension pneumothorax Flail chest with pulmonary contusion Life-threatening bronchospasm Pulmonary oedema

15. BREATHING: races R ate : Normal rate in adults 12-20. Above 30 indicates distress A ir entry: Look and feel for bilateral chest rise; listen for bilateral air entry. C olour: Assess for cyanosis. Also assess for pallor. E ffort: Increased respiratory efforts means the patient is in distress. S ATS Action: Supplement oxygen Treatment of specific disease entities. Definitive air-way and assisted ventilation if necessary

16. CIRCULATION Identify pulses and asses rate, rhythm and character and check BP Assess peripheral perfusion using capillary refill time Assess BP, JVP, the apex beat and listen to the heart for extra sounds Look for obvious source of bleeding in trauma Identify specific shock state and treat all shocked patients promptly. IV access with administration iv crystalloid solution Draw blood for base line lab investigations, cross-match and icon Blood transfusion if indicated Prevent hypothermia Start ECG monitoring

17. DISABILITY This is the Neurological exam The aim is to detect life threatening neurological conditions Check the patient’s pupillary response Equal size Pinpoint opiates/organophosphates, pontine lesion Dilated hypoxia, anticholinergics (e.g. atropine), alcohol, metabolic Unequal size Dilated + Fixed Uncal herniation, IIIrd nerve palsy; 20% of population have unequal pupils

18. DISABILITY 2. Assess the posture Lateralizing signs/lack of movements on one side/tone-power-reflexes Abnormal posturing and movements: intermittent twitching, decortication, decerebration 3. Assess the Glasgow Coma Scale (gcs)/avpu A Alert V Responsive to verbal stimuli P Responsive only to painful stimuli U Unresponsive

19. DISABILITY 4 . Check for any signs of raised intracranial pressure Cushing’s triad (HPT, bradycardia, shallow and irregular respiration) 5. Assess breathing pattern Acidotic breathing ( Kussmaul’s ); agonal breathing (gasping); apnoeistic breathing (rapid irregular gasping); Cheyne Stokes (erratic breathing due to poor brainstem perfusion) 6. Abort and treat any seizures 7. Don’t ever forget to check Glucose!!!! 50ml 50%dextrose if hypoglycaemic if HGT <3,5mmol/L

20. Exposure/Environmental control The aim is to expose the patient so that an adequate complete examination can be performed Prevent the patient becoming hypothermic, measure their temperature Assess rashes – non-blanching, erythroderma, anaphylaxis Swellings and bruises Remember to turn patient on back to examine for injuries to back (log role C-spine patient)

21. Monitoring Pulse Oximetry Respiratory Rate Blood Pressure 12 Lead ECG Monitoring CXR Temperature!!! ABG CVP – When Appropriate (Never use CVP for resuscitation, 2x large bore IV cannulas better) GCS Urinary Catheter (Urinary Output); Nasogastric Tube If Indicated Capnography – If Intubated And Ventilated

22. the Glasgow Coma Scale It is a Neurological scale, aims to give a reliable, objective way of recording the conscious state of a person, for initial as well as continuing assessment Initially used to assess LOC after head injury, now used in acute medical and trauma patients and in chronic patient monitoring Published in 1974 by Graham Teasdale and Bryan J Jennet, professors of neurosurgery the university of Glasgow's institute of neurological sciences at the city's southern general hospital. The pair went on to author the textbook Management Of Head Injuries The gcs measures Eye Opening (E); Best Motor Response (M); and Best Verbal Response (V)

23. the Glasgow Coma Scale – adult Eye Opening (E) Spontaneous 4 To speech 3 To pain 2 No response 1 Best Motor Response (M) To Verbal Command: obeys 6 To Painful Stimulus: localizes pain 5 flexion-withdrawal 4 flexion-abnormal 3 extension 2 no response 1

24. the Glasgow Coma Scale – adult, cont. assessment GCS: 14-15 (Mild head injury ) GCS: 9-13 ( Moderate head injury ) GCS: 3-8 ( Severe head injury ) TOTAL 15 Best Verbal Response (V) Oriented and converses 5 Disoriented and converses (confused) 4 Inappropriate words 3 Incomprehensible sounds 2 No response 1

25. the Glasgow Coma Scale - assessment GCS: 14-15 (Mild Head Injury) Patient awake, may be orientated History obtainable include name, age, time of injury, LOC, amnesia, headaches, seizures Examination – systemic injuries may be present, eg spine & facial bones, do neurological exam Specific investigations – C-spine & other XR as required, blood tests: eg toxic screen. CT ideal in all patients, except completely asymptomatic & neurologically intact patients

26. the Glasgow Coma Scale – assessment GCS: 9-13 (MODERATE HEAD INJURY) Patient may be confused or sleepy, but still able to follow simple commands Initial exam & blood tests as above CT head in all cases If patient to be transported, consider intubation GCS: 3-8 (SEVERE HEAD INJURY) Intubate

27. the Glasgow Coma Scale – paediatrics GCS IN A CHILD: > 2yrs EYE OPENING VERBAL RESPONSE MOTOR RESPONSE 6 Obeys commands 5 Oriented and converses (Appropriate word) Localizes pain 4 Spontaneous Disoriented and converses Normal flexion-withdrawal 3 To speech Inappropriate words Abnormal flexion (decorticate) 2 To pain Incomprehensible sounds Abnormal Extension (decerebrate) 1 No response No response None (flaccid)

28. the Glasgow Coma Scale – paediatrics GCS IN A CHILD: < 2yrs EYE OPENING VERBAL RESPONSE MOTOR RESPONSE 6 Spontaneous 5 Coos, babbles Localizes pain 4 Spontaneous Irritable but consolable Normal Flexion-withdrawal 3 To speech Persistent cries/screams Abnormal flexion (decorticate) 2 To pain Moans/grunts to pain; restless Abnormal Extension (decerebrate) 1 None None None (flaccid)

29. A Prospective Population-based Study of Pediatric Trauma Patients with Mild Alterations in Consciousness (Glasgow Coma Scale Score of 13-14) OBJECTIVE: considerable controversy surrounds the appropriate evaluation of children with mild alterations in consciousness after closed head trauma (Glasgow coma scale [GCS] score of 13-14). The objective of the current study was to determine the incidence of intracranial lesions in paediatric patients with a field GCS score of 13 or 14 after closed head injuries. Methods: the current study is a population-based, multicentre prospective study of all patients to whom emergency medical services responded during a 12-month period. The setting was urban los angeles county, encompassing a patient population of 2.3 million children, 13 designated trauma centres, and 94 receiving hospitals. Results: in the paediatric age group (<15 yr old), 8488 patients were transported by emergency medical services for injuries. Of these, 209 had a documented field GCS score of 13 or 14. One hundred fifty-seven patients were taken to trauma centres, and 135 (86%) underwent computed tomography. Forty-three patients (27.4%) had abnormal results on computed tomographic scans, 30 (19.1%) had an intracranial haemorrhage, and 5 required an operative neurosurgical procedure for hematoma evacuation. Positive and negative predictive values of deteriorating mental status (0.500 and 0.844, respectively), loss of consciousness (0.173 and 0.809), cranial fracture (0.483 and 0.875, and extra cranial injuries (0.205 and 0.814) were poor predictors of intracranial haemorrhage. Conclusion: paediatric patients who have mild alterations in consciousness in the field have a significant incidence of intracranial injury. The great majority of these patients will not require operative intervention, but the implications of missing these haemorrhages can be severe for this subgroup of head-injured patients. Because clinical criteria and cranial x-rays are poor predictors of intracranial haemorrhage, it is recommended that all children with a GCS score of 13 or 14 routinely undergo screening via non-contrast-enhanced computed tomography

30. SECONDARY SURVEY The aims of secondary assessment is to identify and treat all conditions not detected in the primary assessment, seek evidence to formulate provisional diagnosis and prioritise patient’s management

31. SECONDARY SURVEY History: (AMPLE) A – Allergies M – Medications/Mechanism (Trauma) P – Past Medical History/Past Illnesses L – Last meal E – Events leading to incident NOTE: it is important to obtain history from paramedics before they leave

32. SECONDARY SURVEY – cont. Examination Top to toe and systematic approach Don’t forget skin – open wounds, petechial rashes, bruising Always remember the patient’s back Finger or probe in every orifice Re-assessment Monitor condition of patient and check for any signs of deterioration. Assess the effect of treatment given. If any evidence suggests deterioration –return to ‘a’ in primary assessment

33. SECONDARY SURVEY – cont. ADJUNCTS Special investigations should be done especially if diagnosis is unclear Bloods: FBC, UCE, LFT, ESR, toxic screen, ABG, consider malaria smear, blood cultures. Don’t forget to check glucose!!! Urine: dipsticks and MCS CXR CT brain: if normal and no contraindication, proceed to LP Refer patient for definitive management

34. Vitals pulse Tachycardia  Hypovolemia/haemorrhage  hyperthermia  Intoxication Bradycardia  Raised intracranial pressure  Heart blocks Blood pressure Increased  Hypertensive encephalopathy  Cerebral haemorrhage  Raised intracranial pressure Decreased  Hypovolemia  Myocardial infarction  Intoxication/poisoning

35. Vitals Respiratory rate Increased  Pneumonia  Acidosis (DKA, renal failure)  Pulmonary embolism  Respiratory failure Decreased  Intoxication/poisoning Temperature Increased  Sepsis  Meningitis ,encephalitis  Malaria, Pontine haemorrhage Decreased  Hypoglycaemia  Hypothermia (less than 31 C)  Myxoedema  Alcohol, barbiturate, sedative or phenothiazine intoxication.

36. Study on Missed injury in major trauma patients Objectives: to determine the incidence, aetiology and contributing factors to injuries being missed during the primary and secondary surveys in patients with major trauma managed on a general adult intensive care unit (AICU). Methods: the records for patients admitted to the AICU following severe injury (defined as injury severity score (ISS) >16) over a 1-year period were reviewed. Diagnostic imaging performed during the resuscitation was reviewed in cases where missed injuries were discovered. Results: forty-five patients with a median injury severity score of 26 were included in the study. Twelve missed injuries were discovered in 10 patients during the intensive care admission; three required an additional surgical procedure. There was no significant difference in glasgow coma score, revised trauma score, ISS or admission systolic blood pressure between patients with missed injuries and those patients where all injures were found at resuscitation (P>0.05). Three quarters of the undetected injuries were orthopaedic. Conclusions: significant injuries can be missed during the primary and secondary surveys in severely injured patients. A tertiary survey should be completed in all trauma patients admitted to an intensive care unit.

37. APPROACH TO SUDDEN DEATH The medico-legal term “sudden death” (sometimes called "sudden unexpected natural death"), refers to those deaths which are not preceded by significant symptoms. The term as used obviously excludes violent or traumatic deaths.

38. Classification and Definition CLASSIFICATION OF DEATH According to causes: Natural Unnatural – Eg Suicide Homicide Misadventure definition Sudden death is generally considered any "natural," unexpected death that occurs within one hour after symptoms begin. It is the abrupt cessation of all vital bodily functions, manifested by the permanent loss of total cerebral, respiratory, and cardiovascular functions. The WHO’s definition is death occurring within 24 hours of the onset of symptoms A sudden and unexpected death may be a death from an unnatural cause and require police involvement and forensic examination.

39. Causes of Sudden Natural Death Cardiovascular diseases of the cardiovascular system account for the majority of cases of sudden natural death worldwide Coronary artery disease eg atherosclerosis, congenital abnormalities, embolism, arteritis, dissecting aneurysms Non-coronary cardiovascular diseases eg congenital anomalies, valvular heart disease e.g. rheumatic heart disease and syphilis, hypertensive heart disease, myocarditis, ruptured aortic aneurysm - atherosclerotic, syphilitic, dissecting (acute aortic dissection); and cardiomyopathy. Respiratory system: eg pulmonary embolism; massive haemoptysis e.g. Secondary to tuberculosis or malignancy; tension pneumothorax severe pneumonia (viral, bacterial); asthma; anaphylaxis; airway obstruction etc. Central nervous system eg "stroke" – intracerebral haemorrhage; cerebral infarction secondary to atherosclerosis or embolism; subarachnoid haemorrhage secondary to ruptured berry aneurysm, etc. Other include meningitis; epilepsy; brain tumour etc.

40. Causes of Sudden Natural Death – cont. Abdominal eg massive haemorrhage from viscus into peritoneal cavity, duodenal ulcer, gastric ulcer, ulcerative colitis or diverticulitis; malignancy; ruptured ectopic pregnancy; ruptured viscus - bowel, ovarian cysts; fulminant hepatic failure; acute pancreatitis etc. Endocrine - adrenal insufficiency; diabetic coma, myxoedema, parathyroid crisis etc. Iatrogenic - problems related to prescription drugs; sudden withdrawal of steroids; complications of anaesthesia; mismatched blood transfusion etc. Miscellaneous - drug abuse; anaphylaxis; bacteraemia shock; shock from dread, fright or Emotion (vagal inhibition), sickle cell crisis, alcoholism etc. Special causes in children Indeterminate - this category is reserved for those cases in which the cause of death remains in doubt even after an exhaustive study

41. HISTORY Events leading to death: Family collateral Ambulance personnel Nursing staff ID Past medical history Terminal illness Recent admissions Medication Recent surgery Age - different aetiologies

42. EXAMINATION Confirming death Apnoea No pulses or heart sounds Fixed dilated pupils General inspection: External injuries; face: congested or swollen petechial haemorrhages (eg in asphyxiation); neck: bruises, abrasions or marks Livido : gravity dependant, if not lowest part, body has been moved cherry red colour - carbon monoxide poisoning - organophosphate poisoning Time of death Clinically estimated by rigor mortis

43. EXAMINATION cont. If on a ventilator patient may be brain dead even if heart is still beating UK brain death criteria: deep coma with absent respirations absence of drug intoxication or hypothermia (<35C) absence of hypoglycaemia, acidosis & UCE abnormality absent brain stem reflexes (ALL) unreactive pupils absent corneal reflex absent vestibulo -ocular reflex – inject ice water into external auditory canal, if no eye movement occurs, reflex is absent no response if stimulating cranial nerves absent gag reflex` no respiratory effort with rise in paCo 2

44. Certificate of cause of death, BI-1663 The births and deaths registration act, no 51 of 1992 refers to a ‘medical practitioner’ completing the death notification form. In terms of the health professions act, no 56 of 1974, an intern is not a registered medical practitioner. Section 36(2) of the health professions act allows an intern to perform any function or issue any certificate or other document which in terms of any law other than the health professions act itself, may be or is required to be performed by a medical practitioner. It is therefore legally permissible for an intern to complete and issue a DNF. Important information that should be recorded in the DNF include: identity, including residential address of patient for geo-coding; date of death; place of death; cause of death information; whether the cause of death was natural or unnatural; health information including tobacco use, and females’ pregnancy status; certifier section with name, address and signature

45. SPECIAL CASES/considerations Known terminal illness - It is therefore essential to identify patients for whom cardiopulmonary arrest represents the terminal event in their illness and for whom CPR will fail and/or is inappropriate. Patient autonomy must be respected if they do not wish to be actively resuscitated Younger person – investigate fully for possible aetiology: exertion - aortic stenosis, cardiomyopathy, drug abuse Infant - sudden infant death syndrome (SIDS) must be fully investigated Further investigate: Violence, neglect, surgery, anaesthesia in last 48hr, alcohol, suicide, poisoning, cause is unknown, etc

46. Study on: Cardiopulmonary resuscitation performed in patients with terminal illness in Chiang Mai University Hospital, Thailand Background the original target of cardiopulmonary resuscitation (CPR) was victims of acute cardiopulmonary arrest. However, the use of CPR has expanded to a wide variety of patients including those with terminal illness for whom CPR is futile. The objective of this study was to identify the incidence of CPR performed, the severity of illness and the outcome of CPR attempted in terminal illness in a teaching hospital. Methods cardiopulmonary resuscitation attempted in terminal illness was retrospectively assessed from the medical records of hospital deaths with any one of eight life-threatening diagnoses during a 3.5-year period. Results of 532 hospital deaths from terminal illness, 411 records (77.3%) were reviewed and abstracted. Most of the 411 patients had a low pre- cpr functional status. Generally, CPR was performed in 270 (65.7%) cases; 114 of those given CPR (42.2%) initially survived, but all died shortly after the manoeuvre. The high death rate following CPR may reflect both terminal illnesses and the severity of pre-event functional capacity of patients. Conclusion the criteria for cpr in this group of patients need to be re-assessed and use of a cerebral performance categories ( cpc ) score may be helpful. A CPC score of 1 reflected good cerebral performance, 2 and 3 = moderate and severe cerebral disability, 4 = comatose, vegetative stage, and 5 = brain death/organ donation candidate.