CME INDIA Presentation by Dr. Manan Mehta, MD, DM Neurology, Mehta Neurology Center, Vadodara.

Based on deliberation at IDCM, META-CON, Vadodara during annual Conference (14-16 July 2023).

When you get an unconscious patient

• Unconscious Patient → Anxious Doctor.
• Prompt Action Needed.
• A structured algorithm – helps in quick diagnosis and better outcomes.
• The speed with which an unconscious patient deteriorates – can sometimes be very unexpected.
• Conscious → Drowsy → Stuporous → Coma → Death.

Definitions

• Consciousness: State of awareness of self and surroundings. A state which permits other functions: cognitive, motor, sensory.

• Drowsiness: Simulates light sleep Easy arousal. Persistence of alertness for some time.
• Stupor: Awakened only with vigorous stimuli. Absence of meaningful response to external stimuli or inner needs.
• Coma: Unarousable unresponsiveness.

• Confused: State of reduced comprehension, coherence & reasoning. Inattention and disorientation – earliest signs.
• Delirium: Confusion with agitation, hallucinations, tremors, illusions + sympathetic overactivity.
• Acute confessional state – Organic brain syndrome.

Essential Pathophysiology to know

• Two main reasons:
  • Diffuse insult to both cerebral hemispheres.
  • Disruption of the ascending reticular activating system:
    • Midbrain and pons, where signals are carried to the thalamus and cortex.
    • The thalamus plays a crucial role in maintaining arousal.

Know the causes

Approach – History

• Most Important.
• Bystanders and Family Members.
• Recent health – Fever, headache, systemic illness.
• Past – liver, renal issues, Cardiac illness.
• Medical records & Drug history:
  • Diuretics.
  • Anticoagulation.
  • OCPs.
  • Antiepileptic.

Approach – Examination

ABC: The ABC steps are fundamental in the initial assessment and management of unconscious patients in emergency situations. These three requirements for rescue treatments take precedence and are crucial for stabilizing the patient’s condition:

1. Clearing Airways (A): Ensuring the patient’s airway is open and unobstructed to allow for effective breathing. This may involve positioning the patient’s head and neck correctly, removing any foreign objects, or using airway adjuncts if necessary.
2. Breathing Maintenance (B): Assuring proper and adequate breathing by monitoring the patient’s respiratory rate and depth. If necessary, providing oxygen supplementation or assisting ventilation may be required.
3. Sustaining Circulation (C): Maintaining an adequate circulation of blood to deliver oxygen and nutrients to vital organs. This involves monitoring the patient’s heart rate, blood pressure, and peripheral perfusion and initiating interventions as needed to support circulation

Glasgow Coma Scale (Use Online Apps/Download from play store)

The GCS assesses three key components of neurological function:

1. Eye Opening (E): The patient’s response to verbal or physical stimuli in terms of eye opening. It is scored on a scale of 1 to 4, with 4 representing spontaneous eye opening and 1 representing no eye-opening response.
2. Verbal Response (V): The patient’s ability to respond verbally to stimuli, such as questions or commands. It is scored on a scale of 1 to 5, with 5 representing normal conversation and orientation and 1 representing no verbal response.
3. Motor Response (M): The patient’s motor responses to stimuli, which are assessed by observing their movements or responses to commands. It is scored on a scale of 1 to 6, with 6 representing normal voluntary movements and 1 representing no motor response.

Based on the individual scores for eye opening, verbal response, and motor response, the total GCS score can range from 3 (indicating severe impairment of consciousness) to 15 (indicating full consciousness).

Basics Examination

• Vitals – pulse, Bp, SpO2.
• Sugar, ECG.
• Level of consciousness.
• CNS – Focal signs.
  • Neck Rigidity, Kernig’s.
  • Planters.
  • Limbs Weakness.
  • Pupils.
  • Extra ocular Movements – gaze preference.

Basic Examination

• RBS, ECG.
• ABG.
• Routine Blood – Electrolytes, Renal, Liver functions, Infective work up.
• Imaging:
  • CT – suspected Bleed or window period of Ischemic Stroke.
  • MRI – mass lesion, encephalitis, tumors.
  • EEG – mainly to rule out Non convulsive status epilepticus.
  • CSF.

Case 1

• 34/ F.
• No past medical History.
• 9:15 am – sudden, severe, extreme – Headache, Vomiting and LOC.
• O/E – P: 110/min regular, BP- 160/100, SpO2: 96%.
• Drowsy, moves all 4 limbs to pain, Pupils small size, equal and reacting.
• RBS – 98.
• ECG – Sinus tachycardia.
• CT Brain showed:

• SAH – SUBARACHNOID HEMORRHAGE.
• URGENT – CT Angio.
• Neurosurgeon – Coiling/ Clipping.

Case 2

• 65/M, Jain.
• DM – 20 years (glimepiride 4mg/day, Metformin – 1g).
• Slept and didn’t wake up in the morning.
• O/E – P- 116/ min, BP – 150/90, SpO2 – 99%, perspiring.
• CNS – Stuporous, minimal movement to pain, heavy breathing.
• RBS – 36 mg/dl (Diagnosis revealed).

Case 3

• 72/F.
• Diabetic, Hypertensive, Hypothyroid.
• Since morning – multiple episodes of complete unresponsiveness – with spontaneous improvement – 4-5 episodes.
• Sustained falls – twice, but no frothing of saliva or tongue bite.
• O/E – Conscious, oriented and no focal neurological deficit.
• RBS – 160.
• ECG showed CHB-Diagnosis reveled.

Case 4

• 20/F.
• College student.
• Acute onset Loss of consciousness.
• Tightening of limbs, up rolled eye balls, jerking of hands and legs.
• On examination – P – 78/min, Bp- 100/70.
• RBS – 120.
• CNS – Unconscious, moves limbs to pain, shouts on pinching, hyperventilating.

Diagnosis:Pseudo seizure or Paroxysmal Non epileptic seizure like episodes (PNES)

Case 5

• 16-year-old Boy.
• P/h/o Febrile seizure @ 3 years of age.
• Acute onset abnormal behavior followed by unresponsiveness.
• Not regained consciousness for 6 hours.
• Vitals – Pulse – 110/min, BP – 110/70, SpO2: 93%, RBS – 180mg.
• On examination, stuporous, minimal movements of limbs to pain. Pupils – small size, reacting.
• Diagnosis:Non convulsive status epilepticus

CME INDIA Learning Edge

• During the ABC assessment, the other team members should perform the following tasks:
  • Conducting blood tests.
  • Establishing intravenous access.
  • Connecting the patient to a cardiac monitor and oxygen saturation probe.
  • Initiating appropriate oxygen therapy if necessary.

• If there is any uncertainty, it is essential to immobilize the cervical spine.
• The most critical threat is compromised airway and breathing, which can lead to the fastest deterioration. Therefore, in patients with a Glasgow Coma Scale (GCS) score of 8 or lower, or those unable to protect their airway or showing ineffective respiratory drive and poor oxygenation, intubation should be considered.
• Do not forget to ask the following seven questions:
  • 1 – Is this possibly a major anoxic-ischemic insult to the brain?
  • 2 – Could this be related to intoxication?
  • 3 – Is there a possibility of a CNS infection?
  • 4 – Could this be caused by a major metabolic derangement or endocrine crisis?
  • 5 – Is nonconvulsive status epilepticus a potential explanation?
  • 6 – Could this be due to an embolus to the basilar artery?
  • 7 – Is it possible that this is psychogenic in nature?
• In cases where the cause of unconsciousness is initially unclear, immediate and general management principles are applied to stabilize the patient and provide supportive care before a definitive diagnosis is made. The following are key principles of initial management for unconscious patients:
  • Ensure oxygenation: Providing adequate oxygen supply through measures such as oxygen therapy or assisted ventilation to maintain oxygen levels in the body.
  • Maintain circulation: Monitoring and supporting the patient’s blood pressure and heart rate to ensure sufficient blood flow to vital organs.
  • Control glucose: Managing blood glucose levels to prevent complications related to high or low blood sugar.
  • Lower intracranial pressure: Taking measures to reduce pressure within the skull, particularly in cases of suspected brain injury or increased intracranial pressure.
  • Stop seizures: Administering appropriate medications to halt ongoing seizure activity if present.
  • Treat infection: Initiating empiric antibiotic therapy if there are signs of infection or suspicion of an infectious cause.
  • Restore acid-base balance and electrolyte balance: Correcting any imbalances in the body’s acid-base and electrolyte levels.
  • Adjust body temperature: Maintaining a stable body temperature and preventing extremes in temperature that could further harm the patient.
  • Administer thiamine: Supplementing thiamine (Vitamin B1) is important, especially in cases where malnutrition or alcoholism is suspected, to prevent Wernicke’s encephalopathy.
  • Consider specific antidotes (naloxone, flumazenil): Using specific antidotes for known intoxications or drug overdoses if applicable.
  • Control agitation: Managing agitated behaviour and ensuring patient safety during the unconscious state.
• It’s important to note that these principles serve as initial measures to stabilize the patient, and the management will be further refined based on the underlying cause, which is determined through a comprehensive evaluation and diagnostic tests. Treatment should be tailored to the individual’s specific condition and needs. Timely and appropriate management is essential in improving outcomes for unconscious patients.

CME INDIA Tail Piece

Avoid Coma Cocktail Therapy

• “Coma cocktails” is a colloquial term used to describe a combination of medications administered to patients in a coma or altered level of consciousness when the cause is unclear or there are multiple potential contributing factors. The term is not an official medical term, and the use of such cocktails is not a standardized medical practice.
• The approach to treating patients in a coma depends on the underlying cause, and each case should be carefully evaluated and managed by healthcare professionals based on the individual’s specific medical history, clinical presentation, and diagnostic findings.
• In medical settings, doctors may administer specific treatments tailored to the cause of the coma, such as addressing infections, metabolic imbalances, head injuries, or other contributing factors. There is no one-size-fits-all treatment for comatose patients, and the use of a “coma cocktail” is not considered a recommended or evidence-based approach.
• It’s important to seek professional medical attention promptly if someone is in a coma or has an altered level of consciousness, as identifying and addressing the underlying cause is crucial for appropriate management and potential recovery.

References:

1. Cooksley T, Rose S, Holland M. A systematic approach to the unconscious patient. Clin Med (Lond). 2018 Feb;18(1):88-92. doi: 10.7861/clinmedicine.18-1-88. PMID: 29436445; PMCID: PMC6330912.
2. Wijdicks, Eelco FM. “The bare essentials: coma.” Practical Neurology 10.1 (2010): 51-60.
3. https://www.signavitae.com/articles/10.22514/sv.2021.230/htm

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