Approach to
Contents
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Clinical Evaluation
History
Examination
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Lab Evaluation
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Management
Basics
Wakefulness depends on the
integrity of both cerebral hemispheres and the ascending
reticular activating formation of
the brain stem.
Cont..
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The management of an unconscious
patient is never an easy task in
clinical practice
The duty of physician is
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Arrive at diagnosis
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Predict the eventual outcome
History
i)
Onset of coma
(abrupt, gradual)
ii) Recent complaints
( headache, depression, focal weakness,
vertigo )
iii) Recent injury
iv) Previous medical illness
( diabetes,uraemia, heart disease )
v) Access to drugs
( sedatives,psychotropic drugs )
Examination
General physical Examination
i) Vital signs
ii) Evidence of trauma
iii) Evidence of acute or chronic system illness
iv) Evidence of drug ingestion ( needle marks
alcohol breath )
v) Nuchal rigidity (examine with care)
Neurological
Examination
State of consciousness
Obtundation; responds-to verbal
stimuli although slow and
inappropriate.
Stupor; the subject can be aroused
only by vigorous and repeated
noxious stimuli.
Coma; unarousable and
unresponsive.
Respiratory pattern
a ) Hyperventilation - midbrain and upper pons lesion
metabolic diseases e.g. hepatic coma, diabetes and generalised
raised intracranial pressure in its early stages.
( b ) Hypoventilation - medullary, upper cervical spinal lesion
Drug overdose and later stages of cerebral herniation.
( e ) Cheyne-Stoke respiration – usually diencephalic lesion
central transtentorial herniation and obstructive hydrocephalus.
( d ) Ataxic respiration (completely irregular breathing)
brain-stem dysfunction of a diffuse nature
Pupillary size and reaction
Medium to dilated symmetrical pupils fixed to
light structural disease of the brain stem.
Small symmetrical pupils reactive to light
metabolic diseases and drug overdose.
Unequal pupil fixed to light
intracranial mass lesion producing 3rd nerve palsy
e.g in unilateral uncal herniation.
Eye movements
Vestibulo-ocular reflexes – douching of one ear with
cold water produces ipsi-lateral deviation of both eyes
with a contralateral quick phase nystagmus lasting for
1—2 minutes. Use of hot water produces the opposite
effect i.e. contralateral deviation with ipsilateral quick
phase nystagmus. Bilateral douching with cold water
gives rise to downward deviation with upward
nystagmus and with hot water the opposite response.
Absence or abnormal response indicates brainstem dysfunction.
Oculo-cephalic reflexes (Doll's eye movement ) -
Normal response consist of deviation of both eyes to
the opposite direction of head rotation. Again absence
or abnormal response indicates brain-stem
dysfunction.
Motor Responses
This is elicited by applying peripheral noxious stimuli e.g.
pinching of limbs rubbing the sternum to elicit pain.
( a ) Appropriate response – brushing away the source of
stimulus.
{ b ) Inappropriate response - decerebrate or decorticate
rigidity. Motor response is also of localising value.
Paralysed limb will show no response and presence of
hemiplegia can therefore be evident. Decerebrate rigidity
indicates brain-stem damage and if bilateral is usually
associated with a very poor prognosis. Complete
flaccidity with no response to noxious stimuli is often
indicative of severe central nervous system depression
due to drug overdose.
Laboratory
Evaluation
Supratentorial lesions
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Skull radiograph
Computerised tomographic scan
CTscan)
Carotid angiography
EEG ( electroencephalogram )
Infratentorial lesions
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Skull radiograph
CT scan
Vertebral angiography
EEG
Ventriculography
Diffuse neuronal lesions
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Examination of CSF ( cerebro spinal fluid )
Serum glucose, calcium, Na, K, magnesium
Blood gases and PH
Liver and renal functions
Drug levels
Management
Initial Management
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Airway
Breathing
Circulation
Deformity
Exposure
Definitive Management
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In general, management of the comatose patient
depends on the cause. However, while the patient is
undergoing evaluation, it is essential to :
pressure area care
care of the mouth, eyes and skin
physiotherapy to protect muscles and joints
risks of deep vein thrombosis
risks of stress ulceration of the stomach
nutrition and fluid balance
urinary catheterization
monitoring of the CVS
infection control
maintenance of adequate oxygenation, with the
assistance of artificial ventilation
You are in emergency department when an
unconscious patient land in emergency
with B.P 90/50 pulse 92/min and
attendants tell u that the patient suddenly
fell unconscious, how will you approach ?
APPROACH

ABC

Immediate management

Examination

History

Investigations
ABC
ABC
A –Open the
airway
B –breathing
C –circulation
Immediate management

Maintain i.v line, oxygen inhalation
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Blood sample for RBS
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Control seizures
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Consider i.v glucose, thiamine,
naloxone, flumazenil
Examination
Examination
•Vitals
•Skin petechial rash
•Injection marks
•Neurological assessment
•Neck rigidity
•Fundoscopy
•Brainstem reflexes
•Detailed medical
examination
CONTD.
Vitals
1.Pulse
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tachycardia
Hypovolemia/haemorrhage
hyperthermia
Intoxication
bradycardia
Raised intracranial pressure
Heart blocks
CONTD.
2.Temperature
increased
 Sepsis
 Meningitis ,encephalitis
 Malaria ,Pontine haemorrhage
Decreased
 Hypoglycemia
 Hypothermia (less than 31 C)
 Myxedema
 Alcohol, barbiturate ,sedative or
phenothiazine intoxication.
CONTD.
3.Blood pressure
increased
 Hypertensive encephalopathy
 Cerebral haemorrhage
 Raised intracranial pressure
Decreased
 Hypovolemia /hgr
 Myocardial infarction
 Intoxication/poisoning
 Profound hypothyroidism, Addisonian
crisis
CONTD.
4.Respiratory rate
Increased(tachypnae)
 Pneumonia
 Acidosis (DKA, renal failure)
 Pulmonary embolism
 Respiratory failure
Decreased
 Intoxication/poisoning
CONTD.
Skin petechial rash
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Meningococcal meningitis
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Endocarditis

Sepsis,thrombotic thrombocytopenic
purpura
Rickettsial infection
RMS (rocky mountain spotted fever)

CONTD.
Multiple injection marks
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Drug addiction
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Acute endocarditis
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Hepatitis B /C with encephalopathy
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HIV
CONTD.
Neurological
assessment;

General posture
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Level of conciousness
CONTD.
Posture;
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Lack of movements on one side
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Intermittent twitching
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Multifocal myoclonus
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DECORTICATION

DECEREBRATION
CONTD.
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
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CONTD.
An abbreviated coma scale is used in
the assessment of critically ill patient
(primary servey)
AVPU
A –alert
V – respond to voice stimulus
P – respond to pain
U - unresponsive
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Brainstem reflexes
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Pupillary responses to light
Spontaneous and elicited eye
movements
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Corneal responses
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Respiratory movements
CONTD.
Ocular movements
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Conjugate deviation of eyes to a side
– ipsilateral hemisphere frontal
leison or contralateral pontine leison.
Rarely eyes may turn paradoxically
away from the side of deep
hemisphere leison (WRONG-WAY
EYES)
Downward conjugate deviation of
eyes – mesencephalic leison.
CONTD.
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Eyes turn down and inward in –
thalamic hgr and upper midbrain
leison.
Ocular bobbing – is diagnostic of
pontine hgr.
Ocular dipping - indicates diffuse
cortical anoxic damage.
Dysconjugate ocular deviation –
brainstem leison.
CONTD.

Oculocephalic reflex (Doll’s eyes
response) – brisk in cortical
depression ,lost in brainstem leison.
Oculovestibulo responses –two
components
1.Conjugate ocular movement – loss in
brainstem damage.
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2.Nystagmus – loss in damage to
cerebral hemisphere
CONTD.
Pupillary changes;
Sr
no
pupils
causes
1
B/L Pin-point pupils ( less
than 1mm)but responsive
Opiates poisoning
,extensive pontine hgr.
2
B/L small pupils but
responsive
B/L diencephalon
involvement or
destructive pontine
leison
3
B/L slightly small pupils(1
to 2.5 mm) but responsive
Metabolic
encephalopathies ,deep
B/L hemisphere leison
or thalamic hgr.
4
B/L dilated and fixed
Severe midbrain
damage, Overdose of
atropine,scopolamine,
glutethemide.
CONTD.
Sr.
no.
Pupil
cause
6
U/L small pupil
Horner syndrome
5
Ipsilateral dilated
pupil with no direct
or consensual
reflexes
Compression of 3rd
cranial nerve e.g,
uncal herniation
7
U/L small and
irregular pupil
unresponsive
Leison in pretectal
area of midbrain
CONTD.
Respiratory movements
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Has less localizing value then other
brainstem reflexes.
Cheyen-stokes respiration(classic
cyclic form ending with a brief apneic
period – B/L hemisphere damage or
metabolic depression.
Rapid ,deep breathing (Kussmaul) –
in metabolic acidosis and in
pontomesencephalic leison.
Neck rigidity;
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Meningitis
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Subarachnoid haemorrhage
Fundoscopy
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Raised intracranial pressure
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Hypertensive changes
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Subarachnoid haemorrhage
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Diabetic retinopathy
History
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Onset of the symptoms
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Antecedent symptoms
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Use of medications

Chronic liver ,kidney ,lung or heart
disease
CAUSES OF UNCONCIOUSNESS
Thiamine
deficiency
Brain
tumor
epilepsy
metabolic
disturbances
Causes of
unconciousness
infections
trauma
Cardiovascular
disease
Causes of unconciousness
Metabolic
Drugs, poisoning e.g CO ,alcohol
Hypoglcemia, hyperglycemia (keto
acidoti or HONK)
Hypoxia, carbondiaoxide narcosis
(COPD)
Septicemia
Hypothermia
Myxedema ,addisonian crisis
Hepatic / uremic encephalopathy
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CONTD.
Neurological
Trauma
Infections – meningitis, encephalitis,
malaria, typhoid, rabies,
trypanosomiasis.
Tumours – cerebral / meningeal
tumors
Vascular – subdural / subarachnoid
hgr, stroke, hypertensive
encephalopathy
Epilepsy – nonconvulsive status /
postictal state
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Immediate investigations
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RBS
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Blood CP and ESR
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LFTs
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Urea and Creatnine
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Blood and urine cultures
Other investigations
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CRP
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ABGs
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Toxic screen , drug levels
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Lumbar puncture and CXR
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CT scan
Summary
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
Take home message
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Early management
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Prompt diagnosis
MCQ

Pupillary changes in opiate poisoning
1.B/L pinpoint
2.U/L pin point
3.B/L dilated
Answer
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1. B/L pin point
MCQ

Myxoedema coma seen in
1.Euthyroid state
2.Hyperthyroid state
3. hypothyroid state
Answer

3. hypothyroid state
Thank
You