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MBBS 4: Accidents and Emergency > The Unconscious Patient > Flashcards

The Unconscious Patient Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is an unconscious patient?

A

An unconscious patient is a clinical state in which patients have
impaired responsiveness (or are unresponsive) to external stimulation
and are unarousable

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2
Q

What is a coma?

A

state of prolonged unconsciousness
- life threatening

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3
Q

What maintains alertness in a person?

A

Ascending reticular activating system (ARAS) induces and maintains
alertness

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4
Q

Causes of reduced consciousness?

A
  1. focal lesions within the upper brainstem by directly damaging the ARAS
  2. caused by diffuse bilateral hemisphere damage
  3. Alteration in the projections to the cortex through the diencephalon
    before the cerebral cortex also alters mental status
  4. An impaired oxygen or substrate delivery alters cerebral metabolism
    - Interferes with neuronal excitability and/or synaptic function
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5
Q

Sites and causes of coma?

A
  1. diffuse hemisphere
    - trauma, ischemia, hypoglycemia/other metabolic disorders, infection, drugs
  2. bilateral thalamic
    - hemorrhage, infarction
  3. brain stem compression
    - supra or infra tentorial mass lesions
  4. brain stem
    - ischemia, hemorrhage and drugs
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6
Q

Principles of dealing with an unconscious patient?

A
  1. Evaluation must be swift, comprehensive, and undertaken while urgent steps are
    taken to minimize further neurological damage
  2. Keeping the patient alive is more important than the underlying diagnosis
  3. Every unconscious patient must be approached the same way
  4. Try to find cause for unconsciousness and correct it
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7
Q

Is ‘unconscious’ a diagnosis?

A

NOT A DIAGNOSIS
- diagnosis is based on history, thoughtful examination, and the appropriate choice of investigations.
- Accept little or no history

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8
Q

States of consciousness?

A
  1. obtundation
  2. stupor
  3. coma
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9
Q

Obtundation?

A

responds to verbal stimuli although slow and inappropriate

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10
Q

Stupor?

A

the subject can be aroused only by vigorous and repeated noxious stimuli

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11
Q

Coma?

A

unarousable and unresponsive

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12
Q

General approach to unconscious patient?

A

ABCDE - PRIMARY SURVEY

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13
Q

How do we know airway is obstructed?

A

Gurgling, Snoring, Stridor, Apnoea

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14
Q

What to do if airway is obstructed?

A
  1. airway maneuvers
    - head tilt, chin tilt, jaw thrust
  2. Use Airway adjuvants: simple and advanced
    - Guedels/oro or nasopharyngeal
    Note: make sure cervical spine control is done at this stage
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15
Q

What should you find out at breathing?

A
  1. Is the patient breathing?
  2. What is the respiratory rate?
  3. Causes of tachypnoea and bradypnea
  4. What is the respiratory pattern?
  5. Hyper/hypoventilation, Cheyne stoke, Kussmaul
  6. What is the respiratory effort?
  7. Use of accessory muscles
  8. What is the oxygen saturation and is it on or off oxygen?
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16
Q

What to check on circulation?

A

Peripheries warmth, CRT, PR, BP

17
Q

Correlation of PR to BP when BP cuff far off?

A
  • Radial = systolic > 90 mmHg
  • Brachial = systolic >80mmHg
  • Femoral = systolic >70 mmHg
  • Carotid = systolic > 60 mmHg
18
Q

What could tachycardia indicate?

A
  1. hypovolemia/hemorrhage
  2. hyperthermia
  3. intoxication
19
Q

What can bradycardia indicate?

A
  1. raised ICP
  2. heart blocks
20
Q

What to do under disability?

A
  1. GCS
    - <8 you intubate
  2. pupils - size and response to light
  3. lateralizing signs
21
Q

Describe pupillary response to light indicating pathology?

A
  1. Medium to dilated symmetrical pupils fixed to light structural disease of the brain stem.
  2. Small symmetrical pupils reactive to light: metabolic diseases and drug
    overdose.
  3. Unequal pupil fixed to light: intracranial mass lesion producing 3rd nerve palsy e.g. in unilateral uncal herniation.
22
Q

What parameters/vital signs should be considered in exposure?

A
  1. Temperature
  2. External signs of trauma
  3. Rash
23
Q

Causes of increased temperature?

A
  1. sepsis
  2. meningitis
  3. encephalitis
  4. malaria
  5. pontine hemorrhageC
24
Q

Causes of decreased temperature?

A
  1. hypoglycemia
  2. hypothermia <31 degrees
  3. myxedema
  4. alcohol, barbiturate, sedative or phenothiazine intoxication
25
Q

Immediate investigations?

A
  • RBG
  • FBC, ABG
  • ECG
  • CXR
  • U&E, Creatinine; LFT
26
Q

AEIOU tips for altered mental status?

A
  • A is for alcohol.
  • E is for epilepsy (and other forms of seizure).
  • I is for insulin.
  • O is for overdose (and oxygenation).
  • U is for uremia (or underdose).
  • T is for trauma.
  • I is for infection.
  • P is for psychiatric (and poisoning).
  • S is for stroke (and shock)
27
Q

Coma without focal signs or meningism?

A

Most common form
* results from anoxic-ischaemic, metabolic, toxic, and drug induced insults, infections, and post ictal states

28
Q

Coma with focal signs?

A

Intracranial haemorrhage, infarction, tumour or abscess

29
Q

Coma without focal signs with meningism?

A

subarachnoid haemorrhage, meningitis and meningoencephalitis

30
Q

Supportive care?
FAST HUGS IN BED

A
  1. Feeding/fluids
  2. Analgesia, antiemetics
  3. Sedation
  4. Thromboprophylaxis
  5. Head up position
  6. Ulcer prophylaxis
  7. Glucose control
  8. Skin/eye care
  9. Indwelling catheter
  10. Nasogastric tube
  11. Bowel care
  12. Environment –temp, noise, light
  13. De-escalation – end of life, drugs no longer needed
31
Q

Brainstem reflexes?

A
  1. pupillary response to light
  2. eye movements
    - oculocephalic (dolls eye)
    - caloric response
  3. corneal reflexes
  4. respiratory movements
    - cough reflex
    - gag reflexe

MBBS 4: Accidents and Emergency (34 decks)

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