ALTERED SENSORIUM AND CARE OF UNCONSCIOUS PATIENTS

DEFINITION:
CONSCIOUSNESS: Normal cerebral activity Patient is aware of both self and environment Able to respond to internal and external changes

SLEEP: Normal variation in consciousness COMA: Unarousable and unresponsive to all external stimuli

Levels of consciousness:
AWAKE: AROUSED AND AWARE

SOMNOLENT:EASILY AROUSED AND AWARE

STUPUROUS:AROUSED WITH DIFFICULTY IMPAIRED AWARENESS COMATOSE:UNAROUSABLE AND UNAWARE VEGETATIVE STATE:AROUSED BUT UNAWARE

GLASGOW COMA SCALE

ORIGINALLY PROPOSED FOR HEAD INJURIES BASED ON INDICATORS OF CEREBRAL FUCTION PREDICTION OF SEVERITY/OUTCOME/MONITER THERAPY NOT IN THE FIRST FEW HOURS AFTER CARDIAC ARREST

Causes of coma:
METABOLIC: DRUG OVERDOSE HYPOGLYCEMIA DM RENAL FAILURE HEPATIC FAILURE HYPOTHERMIA HYPOTHYROIDISM HYPOXIC ENCEPHALOPATHY

CAUSES OF COMA continued

STRUCTURAL DIFFUSE: MENINGITIS/ENCEPHALITIS SAH EPILEPSY HEAD INJURY HYPERTESIVE ENCEPHALOPATHY

CAUSES OF COMA continued

FOCAL:

HAEMORRAGE INFARCTION HEMATOMA TUMOR ABSESS

APPROACH TO COMA
1. HISTORY Sudden onset: VASCULAR Lucid interval: EDH Headache: SOL Seizures: CEREBRAL Drugs Depression

2. EXAMINATION
IMMEDIATE ASSESSMENT Airway clear? ABG Intubate/O2
Fitting? Glucose iv glucose, thiamine/O2/diazepam Signs of craniofacial trauma? CT/X Ray neurological opinion Neck broken? Splint neck Major hrge? Maintain circulation DM? Treat Drug overdose/misuse? Pupils/ventilation naloxone

Further Assessment:
GCS SIGNS OF HEAD INJURY NECK STIFFNESS PUPILS SIZE/REACTION TO LIGHT OCULAR MOVEMENTS LIMBS REFLEXES AND PLANTER RESPONSE FUNDUS

Metabolic coma
NO FOCAL NEUROLOGICAL SIGNS NO NECK STIFFNESS PRESERVATION OF VESTIBULOGENIC OCULAR MOVEMENT

NORMAL PUPILLARY RESPONSE TO LIGHT

DOLLS HEAD MOVEMENT

ABSENT: EXTENSIVE STRUCTURAL LESIONS IN BRAINSTEM AWAKE PATIENT PRESENT: INTACT VESTIBULAR REFLEX MECHANISMS

COMA WITH NECK STIFFNESS

SAH MENINGITIS ENCEPHALITIS INTRACEREBRAL HAEMORRHAGE CEREBRAL MALARIA

PUPILS
SIZE: UNEQUAL USUALLY THE LARGER ONE IS ABNORMAL RESPONSE: USUALLY NORMAL IN METABOLIC COMA PINPOINT AND UNREACTIVE: PONTINE AND THALAMIC HRGE

PERSISTANT VEGETATIVE STATE

WAKEFUL UNRESPONSIVENESS DIFFUSE CEREBRAL INJURY WITHOUT INVOLVEMENT OF BRAINSTEM RES IMMOBILE WITH DECEREBRATE POSTURING EYES OPEN PRESERVED SPONTANEOUS BLINKING REFLEX SWALLOWING/CHEWING/GAG BREATHES NORMALLY/MUTE DIFFICULT TO ACCEPT THAT THE PATIENT IS AWAKE BUT NOT AWARE

COMA LIKE STATES:

AKINETIC MUTISM LOCKED IN SYNDROME PSYCHOLOGICAL COMA

CARE OF UNCONSCIOUS PATIENT

EVALUATED AND TREATED SIMULTANEOUSLY O2/AIRWAY/RESPIRATION CIRCULATION TO ENSURE CEREBRAL PERFUSION GLUCOSE/THIAMINE TREAT SEIZURES SEDATION IF AGITATED ANTIDOTE TEMPERATURE NUTRITION BED SORES SPECIFIC MANAGEMENT