UNCONSCIOUSNESS

“A state in which a patient is totally unaware of both self and external surroundings and unable to respond meaningfully to external stimuli”

UNCONSCIOUS

“Refers to the part of the mind which is inaccessible to the conscious mind but which affects behavior and emotions”

CONSCIOUSNESS is the state of being aware of and responsive to one’s surrounding.

LEVEL OF CONSCIOUSNESS (LOC) is a measurement of a person’s arousability and responsiveness to stimuli from the environment.

ALTERED LEVEL OF CONSCIOUSNESS is a condition of being less responsive to and aware of external stimuli

CONFUSED: disoriented to surroundings, may have impaired judgment, may need cues to respond to commands.

LETHARGIC: Drowsy, needs gentle verbal or touch stimulation to initiate response.

OBTUNDED: responds slowly to external stimulation and needs repeated stimulation to maintain attention and response

STUPOROUS: responds only minimally with vigorous stimulation, may only moan as a verbal response

COMATOSE: no observable response to any external stimuli

Structural Causes

Trauma: cerebral edema, subdural and epidural hematoma.

Vascular: subarachnoid hemorrhage, infarction.

Infection: meningitis, encephalitis, brain abscess.

Neoplasms: metastatic tumor, primary brain tumor

Metabolic causes

Toxicity: drugs (opiates), heavy metals, carbon monoxide

Systemic metabolic derangement: hypoglycemia, hyponatremia, diabetic ketoacidosis, hyperglycemia,uremia

Hypoxic encephalopathy: severe anemia, severe

pulmonary disease, severe heart failure.

“Cellular brain edema or a disrupted chemical transmission at the receptor site results in faulty impulse transmission and impending communication within the brain or from the brain to other body parts”.

Low blood pressure

Weak and slow/rapid pulse

Pallor

Confusion

Blurred vision

Dizziness

Lightheadedness

Syncope/fainting

Sweating/flushing

Irregular heartbeat

Confusion

Disorientation

Delirium

Lethargy

Stupor

Coma

CASE SCENARIO;

“46 Years old male, with type 2 diabetes mellitus present unconscious with GCS of 3”

Glasgow Coma Scale (GCS) is

a neurological scale which aims to give a reliable and objective way of recording the conscious state of a person for initial as well as subsequent assessment.

It is also useful in the classification of head injury

A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and 15.

14/15 or 15/15 with LOC – Mild head injury

9 -13/15 – Moderate head Injury

3-8/15 – Severe head injury

The AVPU scale is a system by which a health care professional can measure and record a patients level of consciousness. It is mostly used in emergency medicine protocol.

(Alert Verbal Pain Unresponsiveness scale)

Alert: The patient is fully awake (although not necessarily oriented). This patient will have spontaneously open eyes, will respond to voice (although may be confused) and will have bodily motor function

Verbal: The patient makes some kind of response when you talk to them, which could be in any of the three component measures of eyes, voice or motor – e.g. patient’s eyes open on being asked “Are you OK?”. The response could be as little as a grunt, moan, or slight move of a limb when prompted by the voice of the rescuer.

Pain: The patient makes a response on any of the three component measures on the application of pain stimulus, such as a central pain stimulus like a sternal rub or a peripheral stimulus such as squeezing the fingers.

A patient with some level of consciousness (a fully conscious patient would not require a pain stimulus) may respond by using their voice, moving their eyes, or moving part of their body (including abnormal posturing).

Unresponsive: Sometimes seen noted as ‘unconscious’, this outcome is recorded if the patient does not give any eye, voice or motor response to voice or pain.

A – Airway

B – Breathing

C – Circulation

D – Disability

E – Exposure

Stabilize Neck (Neck collar)

Ensure Airway is patent

Suction if necessary

Use of Airway adjunct ( Nasopharyngeal/oropharyngeal airway)

Use of endotracheal tube if indicated

Look, feel and listen for normal breathing

Check for

Symmetry

breathing sounds

tidal volume

respiratory rate

Resuscitation

CPR

Mechanical ventilator may be used to maintain adequate oxygenation

Monitor circulatory status using the following parameters. Blood pressure, heart rate.

Ensure adequate perfusion to body and brain.

Pass an intravenous catheter to provide fluid access

Give adequate intravenous medications

Determine and treat the underlying cause of the LOC

Complete blood count ( Rule out severe anemia evidenced by low RBC’S, decreased PCV. Also, infection, evidenced by elevated WBC’s and differentials).

Blood Glucose ( Rule out Hypo/Hyper glycaemia)

Electrolytes/ Urea/ Creatinine (Rule out electrolyte

derangement as well as uremic encephalopathy)

Imaging Studies

X-ray

CT-SCAN

MRI

The patient clothes should be removed or cut in appropriate manner so that any injury can be seen.

History

Neurological examination

Eye examination

Ventilatory pattern

Fundoscopy

Link unconscious patient to further management after proper and required first aid