Evaluation of Unconsciousness - FM

Question 1

What are the core components of managing an unconscious patient?

Answer 1

History, Examination (GCS/AVPU, pupil size), Investigations, Treatment/Management

Question 2

How is coma defined in an unconscious patient?

Answer 2

A completely unaware patient unresponsive to external stimuli, with only eye opening to pain, no eye tracking or fixation, and limb withdrawal to a noxious stimulus at best

Question 3

What are the two main pathophysiological causes of unconsciousness?

Answer 3

Diffuse cerebral hemisphere insult (e.g., hypoxia, ischaemia, trauma) and disruption of the ascending reticular activating system

Question 4

What are the possible differential diagnoses of non-traumatic unconsciousness?

Answer 4

Metabolic disorders, infections, stroke, epilepsy, drug toxicity, organ failure, etc.

Question 5

What does the Glasgow Coma Scale (GCS) assess?

Answer 5

Eye response, verbal response, and motor response

Question 6

What is the AVPU scale used for?

Answer 6

A quick assessment of consciousness: Alert, Verbal response, Pain response, Unresponsive

Question 7

What is the significance of small pupils (<2 mm) in an unconscious patient?

Answer 7

Opioid toxicity or a pontine lesion

Question 8

What does midsize (4–6 mm) unresponsive pupils suggest?

Answer 8

A midbrain lesion

Question 9

What are maximally dilated pupils (>8 mm) associated with?

Answer 9

Drug toxicity (e.g., anticholinergic overdose)

Question 10

What condition is indicated by mixed and dilated pupils?

Answer 10

3rd cranial nerve (oculomotor) lesion from uncal herniation

Question 11

What is Kussmaul respiration and what does it indicate?

Answer 11

Deep, laboured breathing indicating severe metabolic acidosis, often seen in diabetic ketoacidosis

Question 12

What are the characteristics of ataxic (Biot’s) breathing, and what does it suggest?

Answer 12

Quick, shallow inspirations followed by apnoea, indicating a lesion in the lower pons

Question 13

What does central neurogenic hyperventilation indicate?

Answer 13

Deep and rapid breathing (≥25 breaths per minute), indicating a lesion in the pons or midbrain

Question 14

Why is Cheyne-Stokes breathing not useful for making a firm diagnosis?

Answer 14

It is associated with many conditions and does not point to a specific diagnosis

Question 15

What is the first bedside investigation to perform in an unconscious patient?

Answer 15

Bedside capillary glucose

Question 16

Why should blood glucose be checked even if capillary glucose is normal?

Answer 16

To confirm hypoglycaemia, as capillary glucose may be inaccurate

Question 17

What are the key laboratory investigations for an unconscious patient?

Answer 17

FBC, electrolytes (E/U/Cr), calcium, phosphate, LFTs, clotting profile, toxicology screen

Question 18

What imaging studies are useful in evaluating an unconscious patient?

Answer 18

ECG, CXR, blood cultures, arterial blood gases, brain CT, brain MRI, lumbar puncture

Question 19

Why is EEG performed in unconscious patients?

Answer 19

To rule out non-convulsive status epilepticus

Question 20

When should an unconscious patient be intubated?

Answer 20

If GCS < 8, airway protection is lost, or ineffective respiratory drive is present

Question 21

What is the recommended initial treatment for a patient with hypotension?

Answer 21

IV fluids or vasopressors if MAP < 70 mmHg

Question 22

What is the antidote for opioid toxicity?

Answer 22

Naloxone

Question 23

How should a patient with raised intracranial pressure (ICP) be positioned?

Answer 23

30-degree head tilt position, consider mannitol

Question 24

When should specialist or critical care be involved in management?

Answer 24

Early, when cause is unclear or condition deteriorates

Question 25

Why is early senior intervention necessary in unconscious patients?

Answer 25

To improve outcomes and guide appropriate management