THE UNCONCIOUS PATIENT/ PATIENT WITH ALTERED CONCIOUSNESS

HISTORY FROM PATIENT OR BYSTANDER

TO DIRECT TOWARDS DIAGNOSIS

1. Alcohol abuse & Drug abuse2. Hypertension3. Diabetes & Fasting4. Fever 5. Epilepsy6. Urine output & bowel opening7. Head injury

VITAL PARAMETERS

• RR• PR• BP• Temperature• Capillary Blood Sugar

ANALYSIS of HISTORY

If Alcohol abuse +? Hepatic Encephalopathy? Wernicke’s Encepalopathy? Intoxication ( smell +)

ANALYSIS of HISTORY

If Drug abuse + ? Over dose

ANALYSIS of HISTORY

If Epilepsy + ask what antiepileptic drugs compliance?

ANALYSIS of HISTORY

If Hypertension + ? Stroke ? Hypertensive Encephalopathy

ANALYSIS of HISTORY

If Diabetes +? Hyperglycemia- DKA/ HONK? Hypoglcemia

ANALYSIS of HISTORY

If Fever + ? Meningitis ? Encephalitis ? Cerebral Malaria ? Septic Shock

ANALYSIS OF HISTORY

LOW/ NO urine output - ? ARF- measure BP immediately, catheterize &

monitor UOP ? Shock

NO bowel opening- ? Hepatic encephalopathy

Blood pressure ( 100/70- 140/90)

• High in stroke and Hyertensive Encephalopathy• Low in shocks ( with tachycardia) hypovolaemic shock anaphylactic shock septic shock cardiogenic shock

Pulse rate (60- 100/min)

• High in Shocks & infection

Respiratory rate

• High in shocks & infection• Low in intoxication

Temperature (98.4 ‘ F)

• High in infection• Low in all shocks except septic shock

CBC, U.RE, MP & WIDAL IS MUST

GENERAL MANAGEMENT OF UNCONCIOUS PATIENT

A B C D

1. AIRWAY- Maintain Patency remove FB & denture suck out secretion stat and 2- 4 hrly prop up ( not in shock or cardiac arrest

patients) lateral semiprone position

2. BREATHING- Look for adequacy . If not adequate-

ventilate with ambu bag and O2 connected

if no improvement- intubate

3. CIRCULATION- Look for adequacy No pulse- Start CPR low BP- iv N.saline

iv cannulation is must ( possibly 2)

4. DONOT FORGET CBS treat hypoglycemia

Other important aspects

NG tubing- ? better not feed instead remove the gastric content in most cases

Catherization- most patients need UOP monitoring

Eye care, mouth care, avoid constipation, skin care ( prevent bedsores)

HEPATIC ENCEPHALOPATHY• Altered conciousness + alcoholic

Factors precipitation Hepatic Encepalopathy1. Constipation & dehydration2. Gastrointestinal bleeding3. Infection4. Diuretic therapy5. Dietary protein overload6. Renal failure7. Medications: opiates, benzodiazepines, antidepressants,

and antipsychotic agents

Precipitants should be corrected

• Laculose 45 ml stat through NG tube then every hourly dosing till bowel evacuation occurs.

Then adjust dose to produce 2-3 soft bowel opening per day OR tap water enema to achieve bowel opening

• hydration- iv 5% dextrose with iv thiamine 100mg/ day till recovery

• Antibiotics- o. metranidazole 250 mg tds• Protein withdrawn for 3 days. Then can take

40- 60 g/day• Treat infection with broad sp Ab

WERNICKE’S ENCEPALOPATHY

• Altered conciousness + Alcoholic + these features

• Eyes- Nystagmus, internal strabismus, Nonreacting miotic pupils and complete loss of ocular movements (in advanced cases) & Ptosis.

• Gait- Abnormal

Old- Iv thiamine 100 mg daily for7 days, followed by o thiamine as long as patient drinks

New- Iv thiamine 500 mg tds for 3 days… partial response 250 mg tds for 5 days

DKA and HONK

Altered conciousness + history of diabetes or high CBS

DKA

Rehydration is more important than glycemic control

Monitor PR, BP & UOP to guide rehydration

fluid

• N. saline 1L over 1 Hr 1L over 2 Hr 1L over 4 Hr & 6 Hr

insulin

• Iv infusion of soluble insulin is prefered ( but we don’t have infusion pump! )

• Im soluble insulin 10- 20 units stat then 10 units hrly guided by CBS before

administration ….till CBS 200 mg /dl but keep monitoring

Add all…. Divide by 3 and give as tds dose by subcutAdjust subcut dose by sliding scaleAdd kcl to 2nd bag of N. saline

HONK

Manage precipitating factor1. Infection2. Dehydration3. Trauma & surgery4. MI5. Poor compliance

HYPOGLYCEMIA

SYMPATHETIC OVERACTIVITY

• Tachycardia• Palpitation• Sweating• Anxiety• Cold exteremities

NEUROGLYCOPENIA

• Confusion• Convulsions• coma

Is the patient having 1. Diabetes?2. Aute liver failure?3. Alohol intoxication?

50% dextrose 50-100 ml bolus OR im glucagon 1mg stat

If not available25% dextrose 100 ml bolusContinue iv infusion of 5% dextrose

ACUTE LIVER FAILURE

Altered consciousness + hypoglycemia + icteric

Bleeding tendenciesAcidotic breathing

Test- LFT, PT/INR/ hep serology/ blood grouping & crossmatching

CBS- 2 Hrly- correct with 25% dextrose

Iv vit k 10 mg statIv Ranitidine 50mg 8 Hrly

o. Metra 200 mg 8 HrlyLactulose 45 ml tds

Treat sepsis, seizure & cerebral edemaIf bleeding- fresh blood Transfusion

MENINGITIS

Altered conciousness + fever• Headache• Neck stiffness• Positive kernig’s sign• Photophobia• Focal neurological deficit• Fits

1.Empirical antibiotics iv ceftriaxone 2g 12 hrly (if not available) iv ampicillin 2 g stat & 4 Hrly + iv chloram 1 g stat &

6hrly for 10 days Iv C pen 4 mu stat & 4hrly+ iv chloram 1 g stat & 6hrly

for 10 days

2. iv dexa 8 mg stat & 6 Hrly for 3 days. given 15 min prior to iv ab

3. Treat fever, vomiting, seizure & raised intracranial pressure as needed

ENCEPHALITIS

Similar to meningitis

Iv acyclovir 10mg/kg over 1 hr & 8 Hrly for 10 days

CEREBRAL MALARIA

Altered Conciousness + fever + urgent MP positive or RDT positive

• Hypoglcaemia- monitor CBS 3 Hrly• Shock monitor PR, BP, RR, Temp 6 hrly• Anaemia infusion rate• Seizure

Iv Quinine loading dose- 20mg/kg in 10ml/kg of 5%dextrose over 4 Hr Maintance dose- 10mg/kg 8 Hrly rate not exceeding 5mg/kg/Hr (2-4hr) iv for minimum of 48 Hr. Once oral possibleO. Quinine- 10mg/kg (600mg) 8 Hrly with Clindamycin

20mg/kg/ day/3 for 7 days O.doxy 200mg daily

Im Quinine 10 mg/kg 4 Hrly , better 8 Hrly

Im Artemether 3.2 mg/kg stat, then 1.6 mg/kg daily for 3 days

Iv / im Artesunate 2.4 mg/kg stat, then 1.2 mg/kg after 12 Hr, then

same dose daily for 3 days

Treat fever, hypoglycemia, anaemia, shock & seisure

STROKE & TIA

Altered conciousness with neurological deficit and high blood pressure

• Stroke- sudden onset of focal or global neurological deficit lasting more than 24hr

due to vascular event.• TIA< 24 Hr• Stroke subtypes- ischaemic 80%, IC hemorrhagic 15%, subarach

5%

Ischaemic vs Hemorrhagic stroke

HYPERTENSIVE ENCEPALOPATHY

Altered conciousness + high BP ( typically over 200/ 120)

• fundoscopic changes • Hx of headache & blurring of vision

Iv frusemide 40- 80 mgAim is to reduce DBP to 100mmHg over 1-2 Hrs

EPILEPSY

Status Epilepticus- seisure lasting longer than 30mins or repeated fits without regaining conciousness

All seisures should be treated as Status Epilepticus

• Iv lorazepam 0.1 mg/kg (4mg)OR• Iv diazepam 0.2 mg/kg (10mg)OR can be given twice 5-10mins apart • Per rectal diazepam 0.5mg/kg 5 min 10 min

Per rectal paraldehyde 0.4 ml/kg (10 ml rectally or 5ml im to each buttock)

10 min

Iv Phenytoin 18 mg/kg over 20 min ORMaintainance with Iv Phenytoin 100mg 8 HrlyIv Phenobarbitol 15 mg/kg (< 3months or on phenytoin)

20 min

Consult Anaesthetist or Physician at JDWNRH

• Correct hypoglycemia• If alcoholic- thiamine before glucose• Remember to keep ambubag, oropharyngeal

airway, laryngoscope & ET tube ready…. all drugs used in status epilepticus can cause

respiratory depression

This is the second last slideA THING TO REALIZE

Nurses are not servants to a doctor (they are team- mates) nor they are programmed robots.

They are professional individuals in the field of nursing, capable of analyzing problems in the

patients and taking appropriate step, be it a life saving procedure, stabilization, medication,

monitoring, or informing a doctor.In one way they have won a ticket to earn good

‘karma’ which other professions strive to achieve.

THANK YOU