Sie sind auf Seite 1von 48

HOW TO APPROACH AN

UNCONSCIOUS PATIENT IN
EMERGENCY

Nikhilesh Jain
Director and Chief Intensivist
Dept. Of Critical Care Medicine
CHL Hospitals, Indore
Today's goals

To develop an understanding of a comatose


patient assessment on a first contact basis
Understand the finer nuances of managing
strokes
Looking for differentials in a comatose patient
Initial management of the above subsets
Neural basis

State of awareness of self and surrounding and


cannot be readily defined in terms of anything
else
The use of terms other than coma and stupor to
indicate the degree of impairment of
consciousness is beset with difficulties and more
important is the use of coma scales (Glasgow
Coma Scale and FOUR score)
Coma is characterized by total absence of arousal
and awareness lasting for at least one hour
Definitions of levels of arousal
(conciousness)

Alert (Conscious) - Appearance of wakefulness,


awareness of the self and environment
Lethargy - mild reduction in alertness
Obtundation - moderate reduction in alertness.
Increased response time to stimuli.
Stupor - Deep sleep, patient can be aroused only by
vigorous and repetitive stimulation. Returns to deep
sleep when not continually stimulated.
Coma (Unconscious) - Sleep like appearance and
behaviorally unresponsive to all external stimuli (Un
arousable unresponsiveness, eyes closed)
Disorders of consciousness
Clinical pearls

General examination:
On arrival to ER immediate attention to:
1. Airway
2. Circulation
3. establishing IV access
4. Blood should be withdrawn: estimation of glucose
# other biochemical parameters # drug
screening
Subsequent Assessment

Attention is directed towards


- Assessment of pt.
- Severity of coma
- Diagnostic evaluation
All possible info
- Relatives, paramedics and people who have
witnessed the episode esp. regarding mode of
onset
Prior medical history- DM/Drug history/Epilepsy
Examination- remote trauma, needle marks, log
roll
Points of interest

In case of TBI neck stabilization takes


precedence
GCS for initial management especially in TBI
Brainstem and motor function
Clues in general examination

Pulse
- Bradycardia Brain tumours, myxoedema, opiates
- Tachycardia- Hyperthyroidism, Uremia
BP
- High- Hypertensive encephalopathy
- Low- Addisonian crisis, Alcohol, Barbiturate
Temp
- Low- Hypopituitarism, hypothyroidism, CPZ,
environmental exposure, elderly, cold water
immersion
- High- Infection, Metabolic, vascular,
environmental
Some more clues

Skin- Injuries, bruises, dry, moist, cherry red ,


needle marks and rash
Pupils- Size, equality and reaction to light
- Most metabolic encephalopathies give small pupil
with preserved light reflex
- Structural lesions are more commonly associated
with pupillary asymmetry and loss of light reflex
Mucosal examination

Petechiae &ecchymosis TTP,ITP,DIC,meningococcemia,


vasculitis,endocarditis
Hypermelanosis Addisons, chemotherapy,
porphyria, melanoma
Cherry red skin CO poisoning
Gray blue cyanosis Methemoglobinemia

Telangiectasia Chronic alcoholism, vascular


malformations
Ecthyma gangrenosum Pseudomonas sepsis
Anemia, sepsis ,leukemia,
Splinter hemorrhages' endocarditis
Pigmented macules
Tuberous sclerosis , neuro-
fibromatosis
Daily assessments
Pupils Binstem reflexes
4-pupil & corneal reflex present
3-open pupil wide & fixed Eye response
2-pupil/corneal reflexes absent 4-eyelid open or opened, tracking or
1-pupil & corneal reflex absent blinking to command
0-absent pupil, corneal & cough 3-eyelids open, not tracking
reflexes 2-eyelids closed, open to loud voice, not
tracking
1-eyelids closed, open to pain, not
Respiration tracking.
4-not intubated, regular breathing 0-eyelids remain closed with pain
pattern Motor response
3-not intubated, cheyne-stokes 4-thumbs up, fist, or peace sign to
breathing pattern command
2-not intubated, irregular 3-localizing to pain
breathing pattern 2-flexion response to pain
1-breathes above ventilator rate 1-extensor posturing
0-breathes at ventilator rate 0-no response to pain or generalized
myoclonus/status
How to interpret Pupils
Herniation signs
What about breathing patterns?
Abnormal breathing patterns in coma

Cheynes - Stokes

Central Neurogenic
Midbrain

Apneustic
Pons

Ataxic
Medulla

ARAS
What about motor system?
Asymmetry of tone/movt
Asymmetry of plantar
responses
Tendon reflexes are not
so important
Motor response to DPS
(supraorbital/nail bed)
Flexion of upper limb with
extension of lower limb
(decorticate response)
Extension of upper and
lower limb (decerebrate
response)
Signs of lateralization

Unequal pupils
Deviation of eyes/turning of head to one side
Facial /deep reflexes asymmetry
Unilateral Hyper/hypotonia ,extensor
plantars/focal or jacksonian fits
Epidemiology in a non neurological
ICU

Metabolic encephalopathy-28.6%
Seizures-28.1%
Hypoxic ischemic encephalopathy-23.5%
Stroke-22.1%
Sepsis is major cause of neurological
complication-38.8%
A major break up

Acute stroke- 1-4%


Meningitis/encephalitis
Post reversible leucoencephalopathy
Associations of hypertensive crisis/
encephalopathy
Seizures -0.8-4%
Dys electrolytemias and pH disturbances
Renal/hepatic dysfunction
Hypoxic ischemic encephalopathy
Sepsis (70% in a medical ICU)
Epidemiology in a surgical ICU

Cholesterol embolization
Fat embolus
Multifocal ischemic stroke
Transplants-organ related/procedure
related/therapy related
Supratentorial v/s infratentorial

Starts with focal Affect RAS in pontine


cerebral dysfunction region
Rostral to caudal Involvement of brain
progression stem nuclei/tract with
Signs usually localise a focal findings
single area Sudden onset of coma
(Diencephalon / mid Brainstem signs
brain/brain stem precede/accompany
Asymmetrical motor onset of coma
signs Cranial nerve palsies
are usual
Bizarre resp patterns
at onset
Posturing

Cerebral hemisphere
Decorticate posture
Diencephalon supra
tentorial
Diagonal posture
Upper brain stem
Decerebrate posture
Pontine
Abnormal ext arm
Weak flexion leg
Medullary
Flaccidity
Common patterns
A word about EEG

Fast activity is commonly seen with drug overdose


whereas slow wave abnormalities are more
commonly associated with metabolic and anoxic
coma
An iso electric EEG is more common with drug
induced comas though otherwise it indicates
severe cerebral damage
To summarise.
Primary ABC
Blood for sugar, electrolytes, ABG and osmolality
Sample storage for subsequent screens
Distinguish between metabolic and structural
cause of coma and plan imaging accordingly
LP may be needed
CXR,ECG and EEG (fast activity/slow wave
abnormalities/anoxic coma)
Treatment of cause
Nursing care
Maintain normal physiology
Care of skin and prognostication
How do I identify stroke?

Cincinnati scale LAPPS


What to do next?

Support ABCs with SOS oxygen


Do a pre hospital stroke assessment
Establish time of onset
Transport to a stroke unit with prior relevant info
Neurologic screening assessment
Activation of stroke team
12 lead ECG
Emergent CT scan Brain
What if my CT is fine?
Rule out stroke mimics
Inclusions of fibrinolytic therapy
What if his BP is high?
Supportive things?

Admission to a stroke unit


Monitoring to maintain normothermia, euglycemia
and euvolemia
Treatment of acute seizures
Induced hypothermia
Treatment of UTI/Pneumonia
Swallow assessments
DVT prophylaxis
Treatment of concomitant systemic diseases
Decompressive craniotomy has a mortality benefit
Extending the time windows for
thrombolysis? (3-4.5 hrs)

Inclusions remain the same


Exclusions include age>80 years, INR< 1.7,NHS
scale>25
Even with thrombolysis NHS>20 are known to
have poor outcomes
ICH

Defined as bleeding within the cranial vault


What is my work up gonna be?
Traumatic ICH

Spinal clearance from a neurosurgeon


Racoon eyes/battle sign
ENT consult for skull base fractures
Neurosurgical inputs with mass effect, on going
herniation/obstructive hydrocephalous
Specifics of ICH diagnosis
Initial management
What are my BP targets?
What drugs do I use?

Wait during the initial 24 hrs


Use short acting agents such as esmolol,
hydralazine, enalaprilat, nicardipine or labetalol
Caution with holding beta blockers and clonidine
Complications?
What about anticonvulsants?
Other Supportive measures

Treating ICP with mannitol/HTS (periodic


monitoring of sodium and osmolality) and MV sos
Anticonvulsants
Stress ulcer prophylaxis
Nutrition
Control of temperature, fever and shivering
What if my patient was on an anti
thrombotic agent?
When do I think about neurosurgery?
Summing up

ICH is a neurologic emergency which may require


neurosurgery
Non contrast CT helps
Definitive indications of surgery
Optimizing medical and critical care interventions
goes a long way in improving outcomes
Thank you