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THE UNCONSCIOUS PATIENT

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THE UNCONSCIOUS PATIENT

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    1. THE UNCONSCIOUS PATIENT NPFXH MBBS,FRCS,FCEM

    2. Coma A state of deep, often prolonged unconsciousness, usually the result of injury, disease, or poison, in which an individual is incapable of sensing or responding to external stimuli and internal needs

    3. Coma Unconsciousness = Immediate Life Threat Loss of airway Aspiration

    4. Coma Management of ABCs must come before investigation of cause

    5. Airway Open, clear, maintain If trauma present or no history available, immediately control C-spine

    6. Breathing Assess presence, adequacy High concentration O2 (15Lmin-1via reservoir bag mask) immediately on all patients with decreased LOC Assist if respiratory rate, tidal volume inadequate

    7. Circulation Pulses? Perfusion?

    8. After ABCs stabilized. . . Quickly investigate cause DEFG

    9. D = Depth of coma What does patient respond to? How does patient respond?

    10. E = Eyes Pupils equal, dilated, constricted, Responsive to light? How?

    11. R = Respiratory pattern Rate? Unusually deep or shallow? Altered pattern?

    12. M = Motor Function Evidence of paralysis? Movement on stimulation? How?

    13. Vital Signs Shock? Increased ICP? Arrhythmias?

    14. Head to Toe Survey Injuries causing coma? Injuries caused by fall? What do the scene, bystanders tell you?

    15. Possible Causes Not enough oxygen Not enough sugar Not enough blood flow to deliver O2, sugar Direct brain injury Structural (trauma) Metabolic (toxins, infections, temperature)

    16. Possible Causes Alcohol Epilepsy Insulin Overdose Uremia (and other metabolic causes) Trauma Infection Psychiatric Stroke, syncope

    17. Causes of unconsciousness Focal signs Trauma Intracranial bleed Cerebral contusion Vascular (SAH, Stroke) Subarachnoid haemorrhage Stroke Space occupying lesion Tumour Abscess Diffuse Signs Infection Metabolic/Endocrine Acid-base disturbance Hyper/hyponatraemia Hyper/hypoglycaemia Hepatic encephalopathy Hypothyroidism Toxic Alcohol Recreational drugs Overdose Hypothermia: causes coma when T<320 C Hyperthermia: causes coma when T>420C

    18. Investigations BM stick ECG ABG Temperature Electrolytes ?CT head ?lumbar puncture

    19. Management Secure airway Protective reflexes may be lost Immobilize spine unless absolutely certain injury not present Spinal injury not suspected - patient on left side

    20. Management High concentration O2 Assist ventilation as needed Monitor neurological/vital signs every 5 minutes

    21. Management Protect patients eyes (tape shut, moist pads) Patient may hear, understand even though unable to respond Treat, reassure accordingly

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