Approach to

Contents
Clinical Evaluation
History
Examination

Lab Evaluation

Management
 Basics

Wakefulness depends on the

integrity of both cerebral hemi-
spheres and the ascending
reticular activating formation of
the brain stem.
Cont..

The management of an unconscious

patient is never an easy task in
clinical practice

The duty of physician is

Arrive at diagnosis
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
12 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 brain-
stem 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

Skull radiograph
Computerised tomographic scan
CTscan)
Carotid angiography
EEG ( electroencephalogram )
Infratentorial lesions

Skull radiograph
CT scan
Vertebral angiography
EEG
Ventriculography
 Diffuse neuronal lesions
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

Airway
Breathing
Circulation
Deformity
Exposure
 Definitive Management
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
B breathing C circulation
airway
Immediate management
Maintain i.v line, oxygen inhalation

Blood sample for RBS

Control seizures

Consider i.v glucose, thiamine,

naloxone, flumazenil
 Examination

Examination

Neurological assessment
Vitals
Neck rigidity Detailed medical
Skin petechial rash
Fundoscopy examination
Injection marks
Brainstem reflexes
CONTD.

Vitals
1.Pulse
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

Meningococcal meningitis

Endocarditis

Sepsis,thrombotic thrombocytopenic
purpura

Rickettsial infection
RMS (rocky mountain spotted fever)
CONTD.

Multiple injection marks

Drug addiction

Acute endocarditis

Hepatitis B /C with encephalopathy

HIV
CONTD.

Neurological
assessment;
General posture

Level of conciousness
CONTD.

Posture;
Lack of movements on one side

Intermittent twitching

Multifocal myoclonus

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
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
Brainstem reflexes
Pupillary responses to light

Spontaneous and elicited eye

movements

Corneal responses

Respiratory movements
CONTD.
Ocular movements

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.
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 (Dolls eyes

response) brisk in cortical
depression ,lost in brainstem leison.

Oculovestibulo responses two

components
1.Conjugate ocular movement loss in
brainstem damage.

2.Nystagmus loss in damage to

cerebral hemisphere
 CONTD.
Pupillary changes;
Sr pupils causes
no
1 B/L Pin-point pupils ( less Opiates poisoning
than 1mm)but responsive ,extensive pontine hgr.
2 B/L small pupils but B/L diencephalon
responsive involvement or
destructive pontine
leison
3 B/L slightly small pupils(1 Metabolic
to 2.5 mm) but responsive 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. Pupil cause
no.

6 U/L small pupil Horner syndrome

5 Ipsilateral dilated Compression of 3rd

pupil with no direct cranial nerve e.g,
or consensual uncal herniation
reflexes
7 U/L small and Leison in pretectal
irregular pupil area of midbrain
unresponsive
CONTD.
Respiratory movements

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;

Meningitis

Subarachnoid haemorrhage
Fundoscopy

Raised intracranial pressure

Hypertensive changes

Subarachnoid haemorrhage

Diabetic retinopathy
History
Onset of the symptoms

Antecedent symptoms

Use of medications

Chronic liver ,kidney ,lung or heart

disease
CAUSES OF UNCONCIOUSNESS

Thiamine
deficiency
Brain metabolic
tumor disturbances

Causes of
unconciousness
epilepsy trauma

Cardiovascular
infections
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
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
Immediate investigations
RBS

Blood CP and ESR

LFTs

Urea and Creatnine

Blood and urine cultures

Other investigations
CRP

ABGs

Toxic screen , drug levels

Lumbar puncture and CXR

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
Early management

Prompt diagnosis
MCQ
Pupillary changes in opiate poisoning

1.B/L pinpoint

2.U/L pin point

3.B/L dilated
Answer
1. B/L pin point
MCQ
Myxoedema coma seen in

1.Euthyroid state

2.Hyperthyroid state

3. hypothyroid state
Answer
3. hypothyroid state