APPROACH TO THE
UNRESPONSIVE PATIENT
GREGORY MICK D.O.,F.A.C.O.S
CENTRAL WASHINGTON NEUROSCIENCE
CLINIC
and
Don Hudson, D.O., FACEP/ACOEP
INITIAL CONSIDERATIONS
• THE UNRESPONSIVE PATIENT, ESPECIALLY
WITH A HISTORY OF TRAUMA, PRESENTS US WITH
A STRESSFUL AND CHALLENGING SITUATION
• THERE ARE FEW SURVIVABLE COMPLICATIONS OF
HEAD INJURY THAT WILL KILL YOUR PATIENT IN
THE FIRST FEW HOURS.
• MANY OTHER PROBLEMS CAN, SUCH AS : CARDIAC
TAMPONADE, PNEUMOTHORAX, LACERATIONS OF
MAJOR ABDOMINAL ORGANS, FRACTURESESPECIALLY PELVIC FRACTURES
INITIAL CONSIDERATIONS
cont.
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APPROPRIATE TRIAGE INCLUDES ABC’s
SECONDARY BRAIN INJURY
PREVENTABLE SEQUELAE OF INADEQUATE
OXYGENATION
HYPOTENSION ALMOST ALWAYS IS DUE TO INJURY
OTHER THAN HEAD INJURY
• CUSHING PHENOMENON
• INCREASE IN ICP RESULTS IN DECREASED HR
DECREASED RESPIRATIONS
• MUST ALWAYS ASSUME CERVICAL INJURY
PRESENT
BASIC NEUROANATOMY
• RETICULAR ACTIVATING SYSTEM
• FIBERS ORIGINATING IN BRAINSTEM ,SPREADING
UPWARD INTO THE CEREBRAL HEMISPHERES
• RESEMBLES A BOUQUET OF FLOWERS
• STRUCTURE MOST RESPONSIBLE FOR
CONSCIOUSNESS
• GLOBAL vs. LOCALIZED INSULT
• DUE TO THE ANATOMICAL DESIGN OF RAS,
LESIONS MUST AFFECT ALL OF THE FIBERS IN
ORDER TO CAUSE COMA
BASIC NEUROANATOMY cont.
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TOXIC ENCEPHALOPATHY
DRUG OVERDOSE
DRUG REACTIONS
ENVIRONMENTAL EXPOSURES
METABOLIC ENCEPHALOPATHY
DIABETES
HEPATIC FAILURE
SEPSIS
MENINGITIS
BRAIN METABOLISM
BRAIN UTILIZES ONLY GLUCOSE ,GLUCONEOGENESIS OF
NO USE
BEDSIDE CLINICAL
EVALUATION
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GROSS OBSERVATION
WATCH PATIENT RESPONSE TO INTUBATION (gag)
WATCH EXTREMITIES FOR MOVEMENT(IV START)
PALPATE SCALP
OBSERVE FOR ECHYMOSIS (BATTLE’S
SIGN,RACOON EYES)
FACIAL ASYMMETRY(CRANIAL NEUROPATHY)
• EPISTAXIS
• HEMOTYMPANUM
BEDSIDE CLINICAL EVAL cont.
• LEVEL OF CONSCIOUSNESS
VERBALIZATION
ORIENTATION
• APHASIA
FLUENTvsNON-FLUENT
• PAIN RESPONSE
LOCALIZED vs. GENERALIZED
WITHDRAWAL
POSTURING RESPONSE(FLEXIONvs EXTENSION
• EYE MOVEMENT
DOLL’S EYE (INDICATES MID-BRAIN FUNCTION)
CALORIC TESTING
BEDSIDE CLINICAL EVAL cont.
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PUPILLARY SIZE & REACTION
CORNEAL REFLEX( CN V)
GAG REFLEX ( CNIX & CNXII)
MUSCLE STRENGTH & TONE
DEEP TENDON REFLEXES
BABINSKI & HOFFMAN SIGNS
GLASCOW COMA SCALE
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Pts BEST EYE
BEST VERBAL
MOTOR
6
OBEYS
5
ORIENTED
LOCALIZES
4 SPONTANEOUS CONFUSED
WITHDRAWS
3 TO SPEECH
INAPPROPRIATE FLEXOR
2 TO PAIN
INCOMPREHENSIBLE EXTENSOR
1 NONE
NONE
NONE
Lab and X-ray
• LABORATORY EVALUATION
• CBC, CHEM PROFILE, ABG, URINE & SERUM
TOXICOLOGY, UA, ECG, CXR, APPROPRIATE
C&S
• RADIOLOGY EVALUATION
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C-SPINE X-RAY
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CT OF HEAD
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CT OF QUESTIONALE SPINE X-RAYS
Therapeutic Interventions
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MAINTAIN C-COLLAR UNTIL C-SPINE CLEARED BY
PHYSICIAN
ESTABLISH AIRWAY
ETT vs. TRACHEOSTOMY
ARTIFICIAL RESPIRATION (MAINTAIN NORMAL pCO2)
MAINTAIN ADEQUATE BP
CONTROL ICP/CPP
CPP=MAP-ICP
NALOXONE
MANNITOL/FUROSEMIDE
NIMODIPINE
CORTICOSTEROIDS ????
SZ PREVENTION
GLUCOSE
Your Worries
• Pre-hospital care can be a challenge
• Always assume the worse, c-spine Fx,
blood loss, cardiac event, suicide gesture,
metabolic problems or intra-cranial event