Management of the Unconscious Patient

Question 1

Define consciousness

Answer 1

A state of awareness that allows an individual to react appropriately to an environmental stimulus

Question 2

Causes of altered conscious state

Answer 2

(Revise slip of paper from ICU)
Metabolic (e.g. hepatic encephalopathy, renal failure)
Endocrinological (e.g. hyperglycaemia, hypoglycaemia, hypothyroidism)
CNS (primary, e.g. TBI, CVA, TIA, concussion, epilepsy, or secondary to hypoxia, hypercapnea, CO)
Pharmacological (including EtOH)

Question 3

Value of GCS

Answer 3

Designed for blunt head trauma (not prognostic for non-traumatic LOC)
Gross estimate of cerebral function

Question 4

GCS

Answer 4

Eyes: 4 spontaneous, 3 to verbal command, 2 to pain, 1 nil
Best verbal response: 5 orientated, 4 confused, 3 uses inappropriate words, 2 incomprehensible, 1 nil
Best motor response: 6 obeys commands, 5 localises to pain, 4 withdraws to pain, 3 abnormal flexion to pain, 2 abnormal extension to pain, 1 no response

Question 5

Interpretation of GCS scores

Answer 5

If dead = 3
If comatose = 8
Mild head injury 14 or 15
Score

Question 6

6 important first-line tests for person with reduced conscious state

Answer 6

Blood glucose
FBE
UEC
LFT
TFTs
Cardiac enzymes

Question 7

Suspected meningitis

Answer 7

If there is a possibility of meningitis (i.e. it is in your list of DDx), give Abx before waiting for definitive diagnosis

Question 8

Symptoms of meningococcal septicaemia

Answer 8

Headache
Vomiting
Photophobia
Petechial non-blanching rash
Diarrhoea

Question 9

Tox screen in suspected drug overdose/complications?

Answer 9

Generally don’t do toxicology/drug screen (blood or urine; blood takes 8 hrs, urine takes 4 hrs)

Question 10

GCS of 14 with headache, presenting 1 hour post-LOC

Answer 10

Observe initially

If further deterioration, CT

Question 11

Rapid assessment of conscious state

Answer 11

A - alert
V - response to verbal stimuli
P - response to painful stimuli
U - unresponsive

Question 12

Causes of unresponsive unilateral dilated pupil

Answer 12

Direct ocular trauma
Ipsilateral cerebral herniation: decreased conscious state, associated with HTN and bradycardia, requires immediate intervention

Question 13

Urgent interventions for raised ICP

Answer 13

Elevate head (improve venous sinus drainage)
Mannitol (osmotic diuretic)
Hyperventilation (decrease pCO2 leading to vasoconstriction)
Definitive treatment

Question 14

Ongoing Mx of stable unconscious pt

Answer 14

Maintain vital signs in normal range (esp O2 saturation, BP but also CO2 as a measure of ventilation)
Prevent aspiration (e.g. NGT)
Provide adequate hydration
Manage pressure areas
May need sedation
Will need nutritional support over medium term
Monitoring appropriate for the pt

Question 15

Initial steps for Mx

Answer 15

Initial: assessment and stabilisation of ABC, identifying readily reversible causes e.g. hypoglycaemia
Initial Hx and Ex important to rapidly narrow down DDx

Question 16

CT images

Answer 16

Radiolucent indicates old bleed (weeks-months ago)

Appearance of SAH (blood in subarachnoid space)

Question 17

Norma Jean, 68, is found at 10am in her house by her daughter, unresponsive
What is the initial assessment in ED of the unconscious pain?

Answer 17

Initial evaluation
Vital signs
Focussed examination
Relevant investigations