The Unconscious Patient

Introduction

An unconscious patient is an unresponsive patient who may also have breathing and circulatory problems.
This may be neurological or may result from other systemic diseases
An easy way of finding the cause is to think in terms of the vowels: AEIOU

  • A Apoplexy (stroke)
  • E Epilepsy
  • I Infections e.g. meningo-encephalitis
  • O: Overdosing with drugs, alcohol intoxication, toxins
  • U Uraemia and other metabolic disorders

Other causes include:

  • Head injury,
  • Brain tumours (with complications)

Clinical features

  • Varying levels of impaired consciousness:
    • Comatose: no response to stimulus, however painful
    • Semi-comatose: some response to pain
    • Stuporose: a state deeper than sleep; vigorous stimulation required to stimulate response

Other features:

  • Cessation of respiration or abnormal ventilatory patterns:
    • Cheyne-Stokes, ataxic, apneustic, gasping etc
  • Unresponsiveness or variable response to painful stimuli
  • Features of the underlying cause(s)
    • Stroke: may present with hemiparesis, facial asymmetry, crossed-eye defects, speech defects etc
    • Epilepsy: frothing or tongue biting; abrasions of the extremities; positive past history
    • Infections: may present with fever, neck stiffness.
    • Drug overdosage/toxins: pin-point pupils; respiratory problems; suggestive history
    • Uraemia: characteristic fetor; skin rashes; oedema; severe dehydration
    • Head trauma: haematomas; subconjuctival haemorrhages
    • Bleeding from orifices (if coma is due to trauma or bleeding diathesis)
  • Features of raised intracranial pressure:
    • Slow pulse (Cushing’s reflex)
    • Rising blood pressure
    • Papilloedema

Differential diagnoses

  • Stroke
  • Post-epilepsy state
  • Syncope
  • Mycardial infarction.
  • Hysteria
  • Substance abuse

Complication

  • Cerebral hypoxia/anoxia resulting in brain damage

Investigations

  • Neuro-imaging: CT scan, MRI
  • Random blood glucose
  • Urea, Electrolytes and Creatinine
  • Electroencephalography
  • Cerebrospinal fluid analysis
  • Full Blood Count
  • Drug levels/toxicology screen
  • Blood culture

Treatment objectives

  • Clear airway and restore breathing
  • Nurse in left lateral position and clear secretions by suction
  • Maintain circulation
  • Eliminate the cause
  • Prevent complications:
    • decubitus ulcers
    • atelectasis
    • contractures etc.
  • Correct metabolic derangements
  • Admit in intensive care unit if facility available and connect to a ventilator with monitor

Non-drug treatment

  • Physiotherapy to prevent contractures/deep vein thrombosis, and for passive muscle exercises
  • Nursing care (frequent turning and bladder care) to prevent decubitus ulcers and infections

Drug treatment

  • Infections: appropriate antibacterial agent
  • Epilepsy: use effective parenteral
    anticonvulsant drugs; diazepam (see Epilepsy)
  • Renal failure: dialysis
  • Appropriate treatment of other metabolic causes

Supportive measures

  • Subcutaneous Low Molecular Weight heparin (LMWH) to prevent deep vein thrombosis

Notable adverse drug reactions

  • Diazepam, if required, should be
    administered slowly intravenously to avoid respiratory depression

Prevention

  • Accessible, efficient and effective health care service delivery
  • Early reporting/detection of ill health
  • Adherence to medications and non-drug measures in managing disease states
  • Public Health Education
  • Promote awareness on avoidance of risk factors