APPROACH TO THE UNRESPONSIVE PATIENT

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APPROACH TO THE UNRESPONSIVE PATIENT

• GREGORY MICK D.O.,F.A.C.O.S
• CENTRAL WASHINGTON NEUROSCIENCE CLINIC
• and
• Don Hudson, D.O., FACEP/ACOEP

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INITIAL CONSIDERATIONS

• THE UNRESPONSIVE PATIENT, ESPECIALLY
• WITH A HISTORY OF TRAUMA, PRESENTS US WITH A
  STRESSFUL AND CHALLENGING SITUATION
• THERE ARE FEW SURVIVABLE COMPLICATIONS OF HEAD
  INJURY THAT WILL KILL YOUR PATIENT IN THE FIRST
  FEW HOURS.
• MANY OTHER PROBLEMS CAN, SUCH AS CARDIAC
  TAMPONADE, PNEUMOTHORAX, LACERATIONS OF MAJOR
  ABDOMINAL ORGANS, FRACTURES- ESPECIALLY PELVIC
  FRACTURES

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INITIAL CONSIDERATIONS cont.

• APPROPRIATE TRIAGE INCLUDES ABCs
• SECONDARY BRAIN INJURY
• PREVENTABLE SEQUELAE OF INADEQUATE
• OXYGENATION
• HYPOTENSION ALMOST ALWAYS IS DUE TO INJURY
  OTHER THAN HEAD INJURY
• CUSHING PHENOMENON
• INCREASE IN ICP RESULTS IN DECREASED HR
  DECREASED RESPIRATIONS
• MUST ALWAYS ASSUME CERVICAL INJURY PRESENT

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BASIC NEUROANATOMY

• RETICULAR ACTIVATING SYSTEM
• FIBERS ORIGINATING IN BRAINSTEM ,SPREADING UPWARD
  INTO THE CEREBRAL HEMISPHERES
• RESEMBLES A BOUQUET OF FLOWERS
• STRUCTURE MOST RESPONSIBLE FOR CONSCIOUSNESS
• GLOBAL vs. LOCALIZED INSULT
• DUE TO THE ANATOMICAL DESIGN OF RAS, LESIONS MUST
  AFFECT ALL OF THE FIBERS IN ORDER TO CAUSE COMA

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BASIC NEUROANATOMY cont.

• TOXIC ENCEPHALOPATHY
• DRUG OVERDOSE
• DRUG REACTIONS
• ENVIRONMENTAL EXPOSURES
• METABOLIC ENCEPHALOPATHY
• DIABETES
• HEPATIC FAILURE
• SEPSIS
• MENINGITIS
• BRAIN METABOLISM
• BRAIN UTILIZES ONLY GLUCOSE ,GLUCONEOGENESIS OF
• NO USE

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BEDSIDE CLINICAL EVALUATION

• GROSS OBSERVATION
• WATCH PATIENT RESPONSE TO INTUBATION (gag)
• WATCH EXTREMITIES FOR MOVEMENT(IV START)
• PALPATE SCALP
• OBSERVE FOR ECHYMOSIS (BATTLES SIGN,RACOON
  EYES)
• FACIAL ASYMMETRY(CRANIAL NEUROPATHY)
• EPISTAXIS
• HEMOTYMPANUM

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BEDSIDE CLINICAL EVAL cont.

• LEVEL OF CONSCIOUSNESS
• VERBALIZATION
• ORIENTATION
• APHASIA
• FLUENTvsNON-FLUENT
• PAIN RESPONSE
• LOCALIZED vs. GENERALIZED
• WITHDRAWAL
• POSTURING RESPONSE(FLEXIONvs EXTENSION
• EYE MOVEMENT
• DOLLS EYE (INDICATES MID-BRAIN
  FUNCTION)
• CALORIC TESTING

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BEDSIDE CLINICAL EVAL cont.

• PUPILLARY SIZE REACTION
• CORNEAL REFLEX( CN V)
• GAG REFLEX ( CNIX CNXII)
• MUSCLE STRENGTH TONE
• DEEP TENDON REFLEXES
• BABINSKI HOFFMAN SIGNS

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GLASCOW COMA SCALE

• Pts BEST EYE BEST VERBAL MOTOR
• 6 - -
  OBEYS
• 5 - ORIENTED
  LOCALIZES
• 4 SPONTANEOUS CONFUSED WITHDRAWS
• 3 TO SPEECH INAPPROPRIATE FLEXOR
• 2 TO PAIN INCOMPREHENSIBLE EXTENSOR
• 1 NONE NONE
  NONE

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Lab and X-ray

• LABORATORY EVALUATION
• CBC, CHEM PROFILE, ABG, URINE SERUM
  TOXICOLOGY, UA, ECG, CXR, APPROPRIATE CS
• RADIOLOGY EVALUATION
• C-SPINE X-RAY
• CT OF HEAD
• CT OF QUESTIONALE SPINE X-RAYS

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Therapeutic Interventions

• MAINTAIN C-COLLAR UNTIL C-SPINE CLEARED BY
  PHYSICIAN
• ESTABLISH AIRWAY
• ETT vs. TRACHEOSTOMY
• ARTIFICIAL RESPIRATION (MAINTAIN NORMAL pCO2)
• MAINTAIN ADEQUATE BP
• CONTROL ICP/CPP
• CPPMAP-ICP
• NALOXONE
• MANNITOL/FUROSEMIDE
• NIMODIPINE
• CORTICOSTEROIDS ????
• SZ PREVENTION
• GLUCOSE

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Your Worries

• Pre-hospital care can be a challenge
• Always assume the worse, c-spine Fx, blood loss,
  cardiac event, suicide gesture, metabolic
  problems or intra-cranial event