1) Consciousness is defined as awareness of oneself and one's environment, while unconsciousness is a lack of awareness or responsiveness.
2) Causes of unconsciousness include structural brain lesions, metabolic abnormalities, and psychogenic factors.
3) Assessment of an unconscious patient involves evaluating their Glasgow Coma Scale score, respiration, pupils, brainstem reflexes, and ordering diagnostic tests.
4) Initial management of an unconscious patient focuses on ABCs - airway, breathing, and circulation to optimize oxygen and glucose delivery to the brain while minimizing increased intracranial pressure.
APM Welcome, APM North West Network Conference, Synergies Across Sectors
Causes and Management of Unconsciousness
1. Moderator: Dr. Rachel Andrews
Presenter: Mr. Mahesh Kumar Sharma
M.Sc.(Neurosciences Nsg.) 1st
yr.
2. Consciousness
It is defined as a state of awareness of
oneself and of one’s environment , as well
as a state of responsiveness to that
environment or adaptation to the external
milieu.
6. Unconsciousness
A state of complete or
partial unawareness
or lack of response to
sensory stimuli.
Various degrees of
unconsciousness are
there: e.g. confusion,
stupor etc.
7. Any abnormality of the following areas can
cause unconsciousness:
Bilateral hemispheric abnormality
Brainstem abnormality
Thalamic abnormality
9. Supratentorial lesions
Destructive lesions :
result indirectly from interruption of the blood
supply, leading to infarction, or from direct
injury to the brain.
Compressive lesions:
can compress or distort brain tissue and
arteries, resulting in shifting or herniation of
brain tissue from one compartment to
another.
14. Metabolic /diffuse causes
Diseases of neurons
Metabolic encephalopathy
Diseases of other organs e.g. liver, lungs etc.
poisons, alcohol and drugs
Fluid and electrolyte imbalance
Concussion and Postictal states
Infections
Nutritional deficiency
Hypoglycemia
Anoxia or ischemia
Common fainting
Temperature regulation disorders
21. Coma
State in which a patient is totally
unaware of both self and external
surroundings, and unable to respond
meaningfully to external stimuli.
22.
23. Contd…..
Totally unconscious, unresponsive, unaware, and
unarousable.
Do not respond to external stimuli, such as pain or
light
Do not have sleep-wake cycles.
Coma usually lasts a few days to a few weeks.
After this time, some patients gradually come out of
the coma, some progress to a vegetative state, and
some die.
25. Vegetative state
Opens eyes spontaneously
Does not follow commands
No intentional movements
Show spontaneous roving eyes
Sleep awake cycles
can result from diffuse injury to
the cerebral hemispheres of the
brain without damage to the
cerebellum and brainstem
26. Persistent vegetative state
Many patients
emerge from a
vegetative state within
a few weeks, but
those who do not
recover within 30
days are said to be in
a persistent
vegetative state
(PVS).
27. Locked in syndrome
Caused by damage to
specific portions of the
lower brain and brainstem
with no damage to the
upper brain.
Eye opening is well
sustained
Basic cognitive abilities are
evident on examination
Mode of communication is
eye movements or clinking
of the upper eyelid
28. Akinetic mutism
Patients are immobile
and usually lie with their
eyes closed.
Sleep wake cycles exists.
There is little or no
vocalization.
Motor response to
noxious stimuli is absent
or minimal
Command following or
verbalization can be
elicited but occur
infrequently
29. Brain death
Irreversible damage of the brain, including
the brainstem and cerebellum, and
cessation of functions. Pulmonary and
cardiac functions can be maintained by
artificial means.
Untreated coma causes it.
30.
31. Diagnostic criteria of brain death
THE HARVARD CRITERIA
Criteria Confirmation Duration
Absence of
hypothermia
and drug
intoxication
Unresposive
coma
Apnea
Absent reflexes
Isoelectric
electroencephalo
gram
24 hours
32. THE MINNESOTA CRITERIA
Criteria confirmation Duration
Irrepairable
intracranial
lesion
-No spontaneous
movements
-Apnea when off
respirator for 4 min.
-Absent brainstem
reflexes
-Dilated and fixed
pupils
-Absence of corneal,
ciliospinal, vestubular,
tonic neck and doll’s
eye
-Conventional
angiography
with no filling of
intracranial
vessels
-Cerebral blood
flow studies
demonstrates
no cerebral
blood flow
12 hours
33. Stringent criteria
A pupillary light response
B testing the corneal
response
C injection of ice-cold
water to test the
vestibulo-ocular reflex
D stimulating the glabella
with the knuckle
E stimulating the trachea
with a suction catheter
36. Causes of syncope
Diminished venous return to the heart
Disorders of the pump ( decreased
cardiac output )
Disorders of pathways
Disorders of blood
37. when it is important?
Some forms of syncope suggest a serious
disorder:
those occurring with exercise
those associated with palpitations or
irregularities of the heart
those associated with family history of
recurrent syncope or sudden death
38. Do’ s for syncope
Catch the person before falls.
Have the person lie down with
the head below the level of the
heart.
Raise the legs 8 to 12 inches.
If a victim knows who is about
to faint can lie down right
away, he or she may not lose
consciousness.
39. Do’s
Turn the victim's head to
the side so the tongue
doesn't fall back into the
throat.
Loosen any tight clothing.
Apply moist towels to the
person's face and neck.
Keep the victim warm
40. Don’ts for syncope
Don't slap or shake anyone who's just fainted.
Don't try to give the person anything to eat or
drink, not even water, until they are fully
conscious.
Don't allow the person who's fainted to get up
until the sense of physical weakness passes.
watch for a few minutes to be sure he or she
doesn't faint again.
41. Examination of an unconscious
patient
History
Level of consciousness: assessed with the
help of glass gow coma scale.
EYE OPENING RESPONSE (E)
- Spontaneous eye opening - 4
- Opens to voice - 3
- Opens to painful stimuli - 2
- No response - 1
42. VERBAL RESPONSE (V)
- Oriented, normal conversation -5
- Confused, disoriented -4
- Inappropriate words -3
- Incomprehensible sounds -2
- No response - 1
43. BEST MOTOR RESPONSE (M)
- Obeys command -6
- Localizes pain -5
- Withdraws to pain -4
- Abnormal flexion -3
- Abnormal extension -2
- No response -1
44. Research input : Variability in agreement between
physicians and nurses when measuring the Glasgow
Coma Scale in the emergency department limits its
clinical usefulness.
Holdgate A, Ching N, Angonese L.
Department of Emergency Medicine, Emergency
Medicine Research Unit, Liverpool Hospital,
Liverpool BC, NSW, Australia.
. A senior ED doctor (emergency physicians and trainees)
and registered nurse each independently scored the
patient's GCS in blinded fashion within 15 min of each
other
, a significant proportion of patients had GCS scores which
differed by two or more points. This degree of
disagreement indicates that clinical assessment with
GCS should not be considered as the only mean of
deciding treatment.
53. Oculovestibular test
40 to 60 mL of ice
water is used to
irrigate the ear. If the
brainstem is intact,
the eyes deviate to
the side of the cold
water.
59. CARDIAC STUDY: 12-lead study
TRANSCRANIAL DOPPLER: to rule out
vasospasm.
PET : if available
60. Differential diagnosis b/w different
causes of coma
FOCAL LESIONS:
1) Motor signs unilateral & asymmetrical
2) Signs of dysfunction progress rostral to caudal
3) Comma follows motor abnormalities
4) Pupils unilaterally non reactive; later B/L non
reactive
5) Sudden onset
61. Metabolic coma
1)Confusion and stupor commonly precede motor
signs
2)Motor signs usually are symmetric
3)Pupillary reactions are preserved in most cases
4)Asterixis, Myoclonic, tremor, and seizure are
common
5)Acid-base imbalances are common
62. Psychiatric causes
1)EEG is normal
2)No pathologic reflexes
3)Eupnea or hyperventilation is usual
4)Motor tone is inconsistent or normal
5)Pupils reactive or dilated
6)Lids close actively
63.
64. Syncope :
Vasovagal syncope
Lower head end at onset
Postural hypotension
Hyperventilation
Reassurance & exercises to control breathing
Cardiac arrhythmias
Pharmacological or implanted pacemaker control
of cardiac rhythm.
65. Contd …
Hypoglycemia
Attention to drug regime in diabetes
Removal of insulinoma of pancreas
Vertebro basilar TIAs
Treat source for emboli—Aspirin
Epilepsy
Anticonvulsant drugs
Hysterical attacks
Try to establish the reason for this behaviour
Careful explanation to the patient
68. B minimize the adverse effects of metabolic and
structural disturbances, with particular reference to
raised intracranial pressure (ICP)
69. Contd…….
Hyperventilation
Helps to reduce raised ICP by removing extra
CO2 and causing vasoconstriction ,thus
decreasing raised ICP.
Pharmacological treatment
Mannitol : 0.5 mg/kg over 15 min and repeat
after 4 hrs.
70. Steroids : Dexamethasone
Loop diuretics : inj. Lasix 40 mg stat
Antihypertensives
Surgical interventions: ventriculostomy for
draining CSF.
71. Treatment of underlying causes
Hypoglycemia : 50 ml of 50% D IV push
wernicke’s encephalopathy :thiamine
Drug overdose :naloxone
Seizures : antiepileptic
Infection :antibiotics
Hyperglycemia: insulin
Poison ingestion: gastric lavage
75. Nsg .problems
high risk for Airway obstruction r/t loss of
swallowing, gag and coughing reflexes.
Clear the airways of any foreign body and loosen
any tight clothing
If suspecting spinal injury, do not move the patient
without neck collar.
Use jaw thrust method to resuscitate the patient .
Place the patient in lateral or semi prone position.
Intubation may be required to maintain the airways
76. High risk for aspiration r/t ineffective airway
clearance and absent gag reflex.
place in lateral position to allow the drainage of
secretions
assess for breath sounds every 2-4 hourly
do trachoebronchial suctioning
while giving mouth care, place the patient with the
head turned to one side.
Monitor ABG and other parameters.
77. high risk for altered cerebral tissue perfusion
r/t increased ICP.
assess LOC including alertness and orientation 2-4
h.
assess pupillary size, position, response to light
and consensual response
assess EOM 1-4 h
cognitive function may be impaired by edema and
inadequate blood flow
note verbalization and response to verbal
commands by checking hand grip and release, leg
movements dorsiflexion and plantar flexion 1-4 h
in unconscious client note spontaneous
movements, withdrawal to pain 1-4hs
78. report if any deterioration occurs
monitor temperature 2 h and give hydrotherapy if it
is more than 38.5c
monitor cardiovascular and pulmonary status, vital
signs
elevate the head end of the bed by 30 degrees
monitor intake and output 4h
avoid extreme hip flexion
monitor Hb and Hct
assess for sign of bleeding
check for hematuria
administer blood and blood products
79. research input : The relationship of selected nursing
activities to ICP.
Rising CJ.
Dakota Hospital, Fargo, North Dakota 58103-6014.
Selected nursing measures--turning, suctioning and
bathing--were recorded on the data collection tool as
they occurred. Suctioning and turning were noted to be
associated with an increase in ICP; however, a
sustained increase in ICP was not observed.
These findings further support the need for nurses to be
aware of the patient's ICP prior to turning and suctioning.
80. high risk for injury r/t unconscious state
provide padded side rails
prevent injury due to invasive lines a nd
equipments
any kind of restrain is likely to be countered by the
patient with resistance, leading to self injury or to a
dangerous increase in ICP
give adequate support to the limbs when moving
an unconscious patient
protect them from external source of heat
protect during seizures or periods of agitation
81. high risk for altered oral and nasal mucous
membrane r/t NPO status, inability to swallow
and unconsciousness
inspect the pt.’s mouth
keep the lips coated with water soluble lubricant
give oral hygiene 8 h
avoid agents with lemon and alcohol as they cause
dryness
suction the secretions
clear the nostrils with swab
82. high risk for impaired skin integrity r/t
immobility and loss of protective reflexes
-check for any signs of redness and excoriations at
the pressure points
-Turn the patient from side to side every 2 h
-unconscious women need perineal care
-apply protective eye coverings with adhesive tape
-use water mattresses and water filled bags to
protect form pressure sores
83. High risk for contractures r/t immobility
maintain the extremities in functional position by
providing support
hand rolls prevent flexion contractures of the
fingers
Cock up arm splints prevent wrist drop
Splints, casts or high topped tennis shoes help
properly supprt feet
Remove these support devices 4 h for skin care
and passive exercises.
84. Altered nutrition ;less than body requirement r/t
inability to eat secondary to unconsciousnes
IV fluids are given initially
Nutritional and fluid needs are met through NG feed but only
when:
Patient does not have paralytic ileus or delayed gastric
emptying
Bowel sounds are audible
Gastric residual volume is less than 100 ml/hr
Nursing responsibilities in tube feeding are critical as the
patient:
– Cannot communicate
– May have lost protective cough and gag reflexes
As consciousness returns test the client’s ability to suck and
swallow
Once a client can safely swallow, begin small oral liquid
feedings
85. High risk for fluid volume deficit r/t inability to
drink and respond to normal thirst mechanism
monitor intake and output every 4 h
assess and document any sweating, diarrhea,
polyuria and vomiting
assess blood urea, creatinine, sodium and
potassium
Over hydration and intravenous fluids with glucose
are always avoided because cerebral edema may
follow
86. high risk for bowel incontinence r/t
unconsciousness
examine the patient for abdomen distension
small and frequent stool may indicate fecal
impaction
maintain a regular schedule of stool softners,
suppositories and digital removal
begin a programme of bowel training
87. altered elimination r/t
unconscious state
there can be urinary retention
or incontinence
if any sign of retention then
place an indwelling catheter
palpate the bladder for
distension
an external drainage for the
male patient and absorbent
pad for female can be used
as soon as patient regain
consciousness, start bladder
training
88. altered communication r/t unconsciousness
explain all the procedures before carrying out them.
Do not whisper at the bed side.
Never shout or blame the patient
Don’t discuss about the patient’s condition with the
relative at the bed side
locked in syndrome patients communicate via blinking so
respond to them appropriately
be calm , gentle and patient
help the family members to communicate with the patient
and encourage them to talk effectively.
89. Communication with critically ill patients.
Alasad J, Ahmad M.
Department of Clinical Nursing, University of Jordan, Amman,
Jordan. jalasad@ju.edu.jo
a study that investigated the experiences of a group of critical
care Jordanian nurses concerning verbal communication with
critically ill patients.
: Communication with sedated or unconscious
patients in intensive care units should not be viewed
as only an interactive process. Rather, it should be
perceived as the means to give the information and
support that such patients need.
90. altered family process r/t
family member in coma
explain about the condition
of the patient
encourage them to clear
their doubts and involve
them in patient care
when a patient is not
expected to survive then
explain the family members
about prognosis
91. COMA STIMULATION PLAN
TACTILE stimulation
KINESTHETIC stimulation
OLFACTORY stimulation
ORAL stimulation
AUDITORY stimulation
VISUAL stimulation
92. Research input :
The effect of familiar and unfamiliar voice treatments on
intracranial pressure in head-injured patients.
Treloar DM, Nalli BJ, Guin P, Gary R.
University of Florida, College of Nursing, Gainesville 32610.
to investigate effects of verbal stimulation on ICP in head-injured
patients.
The familiar voice message was played to each subject.
After a rest period, the unfamiliar voice message was
played. ICP was recorded before, during and after
playing both taped messages.
suggest families of head-injured patients with
normal ICP can verbally interact with the
patients for short periods without significant
increases in ICP.
93. Organ donation
Organ donation : is the removal of the
tissues of the human body from a person
who has recently died, or from a living
donor, for the purpose of transplanting or
grafting them into other persons.
95. Three most common causes for
this non donation or mismatch are
family refusal
non recognition or delayed determination
of brain death
loss of donors due to profound
cardiopulmonary and metabolic instability
96. Nurses role in organ donation:
to identify potential donors and contact the
appropriate source to verify if the patient is
eligible for tissue or organ donation.
A thorough assessment to be done by
taking history and doing physical
examination, to confirm with the diagnosis.
97. Contd….
A nurse must be familiar with types of
donation and donation criteria .
offer the family the option for donation,
and provide bereavement support .
become familiar with different religious
positions regarding tissue and organ
donation
98. Organ and tissue donation: a trustwide perspective
or critical care concern?
Elding C, Scholes J.
Brighton and Sussex University Hospitals Trust, Royal
Sussex County Hospital, Eastern Road, Brighton, UK.
christine.elding@bsuh.nhs.uk
to assess the current level of knowledge, confidence and
value system staff have, working in all areas of the
hospital setting in relation to organ and tissue donation
. Education strategies that adopt an experiential
approach should be developed in order to create
confidence in healthcare
99.
100. Conclusion
Altered level of consciousness place a
client at the risk of injury.
Nurse play a very important role in caring
for an unconscious patient, helping the
patient in carrying out ADL.
Proper assessment and prompt
intervention can improve the prognosis.