Unconscious Patient

What is Unconscious Patient?

Consciousness refers to our ability to understand ourselves and our surroundings and to react to what’s happening around us. When our alertness or wakefulness is reduced or we’re less aware of ourselves and our surroundings, it’s called impaired consciousness. Some people might naturally recover full consciousness without needing medical help, but others may need intensive care and detailed medical check-ups.

A coma is a deep state of unconsciousness that can sometimes last for a long time. According to certain experts, a person in a coma stays unresponsive with their eyes closed and cannot be woken up or respond to stimuli, even if they’re strongly stimulated. Doctors use something called the Glasgow Coma Scale (GCS) to understand how severe a coma is. The GCS is helpful as it indicates what a patient’s outcome might be, especially in cases of injuries like traumatic brain injuries, bleeding around the brain called subarachnoid hemorrhages, or conditions like bacterial meningitis.

When patients are unconscious, they lose their protective reflexes and sensory responses, which makes them susceptible to health risks such as aspiration (accidentally inhaling food or drink), anoxic brain injuries (damage to the brain due to lack of oxygen), airway blockage, and skin sores. The reasons for prolonged unconsciousness can either be temporary or permanent. Potential causes of reduced consciousness involve damage to parts of the brain, including the ascending reticular activating system (RAS, which plays a crucial role in maintaining consciousness and wakefulness), and cerebral hemispheres, or interruptions due to toxins or metabolic issues.

This overview aims to explain the causes and physical aspects of reduced consciousness, emphasizing the important role of healthcare professionals in evaluating and managing this condition to improve a patient’s outcome and reduce potential complications.

What Causes Unconscious Patient?

The RAS, or Reticular Activating System, is a part of your brain that plays a critical role in keeping you conscious and aware. It starts from the upper part of your brainstem and extends to different parts of your brain including the thalamus, hypothalamus, and the cerebral cortex. Anything that damages or changes the RAS, including changes to your brain’s metabolism, could affect your consciousness.

Damage that affects consciousness usually involves both cerebral hemispheres, or the two halves of your brain. If the damage only happens to one side, it has to be severe enough to also impact the other half of the brain or the brainstem.

The main reasons for changes in consciousness include structural brain issues, systemic issues that can affect brain function, and in rare cases, psychological issues.

Structural issues can be caused by things like a stroke or a traumatic brain injury (TBI). These problems can either damage a specific part of the brain directly, or cause harm indirectly by applying pressure or increasing the fluid pressure inside the skull. High fluid pressure in the skull can reduce the flow of blood to the brain, potentially causing distortion of brain tissue and the brain slipping out of its normal position inside the skull.

Systemic issues include things like low blood sugar (hypoglycemia) or cold body temperature (hypothermia). These problems interfere with the supply of oxygen or other important substances to the brain, disrupting brain metabolism and impairing the functioning of nerve cells.

Psychogenic unresponsiveness is a psychological condition where a patient may not respond or responds less than usual to external stimulation. This could be characterized by maintaining a certain posture, having involuntary eye movements when the inner ear is stimulated, or resisting when someone tries to open their eyes.

Common causes of unconsciousness that doctors often see in the emergency room include stroke, coma due to lack of oxygen, drug overdose or poisoning, and changes in metabolism such as problems with hormone levels or the balance of acids and bases in the body.

Risk Factors and Frequency for Unconscious Patient

There are varying reasons for a change in consciousness levels between different places and patient groups. For example, trauma hospitals often see a large number of patients unaware due to traumatic brain injuries (TBIs). The most common reasons for non-trauma related changes include hemorrhagic strokes, anoxic brain injuries, poisonings, and metabolic conditions.

Whilst strokes are generally the main cause of non-traumatic coma, non-structural reasons, which range from 37% to 75%, slightly outnumber structural causes, which range from 28% to 64%.

The range of death rates varies significantly; they can be anywhere between 25% to 87%.
Strokes and anoxic comas have the highest death rates, from 60% to 95% and 54% to 89%, respectively.
On the other hand, epilepsy and poisoning have the lowest death rates, with less than 10%.

Signs and Symptoms of Unconscious Patient

When a patient is unconscious, it’s very helpful to gather medical history from people who know the patient’s recent health status. This could be family members, witnesses, or paramedics. Going through old hospital records and even checking personal items like wallets or alert bracelets can also offer clues. It’s important to find out the timeline of when consciousness was lost, the patient’s medication, any recent sicknesses, and symptoms experienced before they passed out.

Looking at individual vital signs, breathing patterns, and skin abnormalities can hint at many possible diagnoses. The eyes can also provide useful information. For example, papilledema might be a sign of increased pressure in the brain, Roth spots could suggest bacterial endocarditis, and a problem with the pupillary light reflex might be due to a lesion in the brainstem or mesial temporal structures being pushed down. Aside from specific substances known to cause miosis or mydriasis (constriction or dilation of the pupils), poisons usually don’t affect pupil size much. If there are fractures and wounds, it generally means the patient has endured trauma.

The neurological examination is crucial as it helps identify the location and nature of any neurological issues and assesses the patient’s chances of recovery. The exam is most reliable when the patient’s blood supply, body temperature, blood sugar, and effects of any neurologically important toxins or medications are all normal. A scale called the GCS can be used to measure the severity of the coma and predict the outcome. Observing natural movements, muscle tone, and reflexes can help identify conditions such as hemiplegia and brain lesions.

Testing for Unconscious Patient

If a patient is found to be unconscious, the first step is to check the vital things such as their pulse and to see if their breathing is stable. In cases where the patient doesn’t have a pulse or their breathing isn’t regular, immediate actions such as basic or advanced cardiovascular life support, should be taken. If their pulse and breathing is stable, the medical team proceeds to a general physical and neurological examination.

The team tries to assess how responsive a patient is. They would start by trying to communicate with the patient, then progressing to gentle physical stimulation, and then more intense stimulation if necessary. In the situation where none of these methods seems to wake the patient up, the medical team may apply some pressure along the chest bone of the patient. The best way to report a patient’s level of responsiveness is to give a detailed account of the patient’s reaction to these external stimuli. The Glasgow Coma Scale (GCS) and the Full Outline of UnResponsiveness (FOUR) are tools often used to assess the patient’s responsiveness. The outcome of these assessments should be documented every day.

Both the GCS and the FOUR scoring systems rate eye, motor, and verbal responses. The GCS scoring system also ranks eye responses from 4 (eyes open spontaneously) to 1 (no eye opening). Individual movements are also graded from 6 (obey commands) to 1 (no motor response). The FOUR Score Assessments also follow this similar grading system. The highest GCS score is 15 (mild) and the lowest is 8 (severe).

The medical team will also have to observe the patient’s eyes. The size and reaction to light of the pupils (the dark central part of the eyes) are important to document as they can hint at increased pressure inside the skull. The team will also conduct an eye examination using a special tool called a funduscope, which can reveal signs of damage to the back part of the eye (such as swelling or bleeding). The medical team can also test the function of certain nerves within the head by checking eye movements, and reactions to corneal (outermost part of the eye) stimulation.

Muscle tone and reflexes are also checked by observing body movements. Certain abnormal posturing or movements of the body can suggest damage at certain levels of the brain. Neuroimaging techniques such as a computed tomographic (CT) scan of the brain can give valuable insights about the presence of abnormal changes inside the brain such as bleeding, clot, swelling, or other brain injuries. Serum tests and other diagnostic imaging tests can also offer further useful information. In some cases, a lumbar puncture (a procedure in which a needle is inserted into the lower part of the spine to collect fluid for testing) might be necessary. The fluid collected during this procedure can be tested for various diseases such as infections. Finally, an electroencephalogram (EEG), a recording of brain activity, might be performed to check for signs of seizures.

Treatment Options for Unconscious Patient

When someone becomes unconscious and the cause isn’t immediately clear, doctors typically start treatment before they’ve finished diagnosing the patient. The first step involves starting some form of treatment while the doctors perform tests to figure out what’s going on. Here are some common steps they might take to treat an unconscious patient:

Oxygen: If the patient’s oxygen levels are too low, they aren’t responding to stimuli well or their cough or gag reflexes are weak, doctors might decide to put a tube down their throat to help them breathe.

Circulation: Keeping the patient’s blood flow in a healthy range is crucial. Doctors might use fluids or medications that help control blood pressure, known as vasopressors, if blood pressure falls below a certain level. If blood pressure is too high, they might use a specific medication to lower it.

Vital Signs: The medical team will likely check vital signs like heart rate, breathing rate, temperature, and blood pressure if they haven’t already.

Glucose Administration: If doctors aren’t sure why the patient is unconscious, they might give them a glucose, a type of sugar your body needs for energy. They do this while waiting for lab test results.

Thiamine Administration: Thiamine is a type of vitamin that the body needs to function properly. If a patient is malnourished, doctors might give them thiamine before or at the same time as the glucose.

Specific Antidotes: If doctors think a drug overdose might be causing the problem, they could give the patient a particular antidote. They might also use a few other methods to try and remove the drug from the patient’s system.

Intracranial Pressure: If there’s too much pressure in the patient’s brain, doctors might administer a certain drug and perform a procedure to lower this pressure.

Seizures Control: Managing seizures is important in unconscious patients. Doctors might use specific medications for this purpose.

Infection Treatment: If doctors suspect that bacterial meningitis or viral encephalitis may be causing the patient’s unconsciousness, they may administer antibiotics or antiviral medication.

Acid-Base and Electrolyte Balances: Doctors will work to maintain the right balance of fluids and electrolytes in the patient’s body.

Body Temperature: Keeping the patient’s body temperature above a certain level is crucial, as higher temperatures can make brain damage worse. Therefore, doctors might use cooling blankets and various medications. In cases of cardiac arrest, they might cool the body because it can help protect the brain.

Agitation Control: Doctors will use the diagnostic test results to create a more personalized treatment plan for optimal results. If patients remain unconscious despite initial treatment, they may need more intensive care in an intensive care unit.

There are a multitude of reasons why someone might lose consciousness, and the path to determining the root cause can be quite complex. While it might be relatively easy to identify some causes like brain damage from a lack of oxygen, stroke, seizures, or poisoning, other categories can carry a wide range of potential reasons. For example, someone might lose consciousness for metabolic reasons such as liver disease, kidney disease, abnormal levels of electrolytes in their blood, or certain hormonal disorders. Other health issues like infections, shock, problems with body temperature regulation, respiratory failure, and physical trauma can also cause unconsciousness.

When a healthcare provider is evaluating an unconscious patient, they also need to identify if the cause is organic or psychogenic (related to mental health) in nature. For example, mental health conditions like catatonia, severe depression, conversion disorder, and malingering can lead to a state of unconsciousness. Signs of psychogenic unconsciousness can include closed eyelids, reacting pupils, abnormal eye movements, varying muscle tone, normal breathing rhythm or rapid breathing, no abnormal reflexes, and normal electrical activity in the brain (as seen in an EEG test). Sometimes brain disorders can mimic mental health conditions, so a diagnosis of psychogenic coma should be made only after careful medical and neurological evaluations.

To make it easier to understand, here’s a list of potential causes of unconsciousness grouped into three categories of structural, systemic, and psychogenic causes:

Structural Causes: Structural problems within the brain can include stroke, traumatic brain injuries (TBIs), brain tumors, inflammation, venous thrombosis, hydrocephalus, locked-in syndrome, akinetic mutism, and different types of brain bleedings.

Systemic Causes: Systemic problems can contribute to unconsciousness, such as low or high blood sugar, low or high sodium levels, high levels of calcium, seizures, systemic infections, meningitis, encephalitis, adrenal crisis, pituitary apoplexy with hormonal insufficiency, endocrine abnormalities, deadly form of hypothyroidism (myxedema coma), drug overdose, illicit drug use, neuroleptic malignant syndrome, excessive alcohol intake, liver disease, kidney disease, heavy metal poisoning, malaria, aspergillosis, herbicides, carbon monoxide poisoning, and anesthesia.

Psychogenic Causes: Mental health conditions, including catatonia, severe depression, conversion disorder, and malingering, can also lead to a state of unconsciousness.

What to expect with Unconscious Patient

The recovery chances of unconscious patients can differ greatly based on a number of things. These can be the cause of the unconscious state, how severe the brain injury is, and unique aspects about the patient themselves. The GCS or Glasgow Coma Scale is a system doctors use to understand a patient’s condition. However, artificial ventilation and sedative medications can affect this system’s accuracy. So, the ideal way is to use the GCS when the patient is first admitted, before any treatment is given.

The FOUR score is another method like the GCS but it’s more complicated and hasn’t been used for as long as the GCS. Traumatic brain injuries (TBIs) have been the most researched cause of coma due to their high occurrence and variable results. Patients in a coma because of a TBI have a mortality rate—the rate of death—ranging from 40% to 50%. Various factors such as patient’s age, motor skills, eye-related signs, additional injuries, and the length of the coma all go into predicting the outcome.

Patients who become unconscious from non-traumatic causes and do not recover quickly often have lower chances of a beneficial outcome compared to patients with TBIs. The mortality rate for non-traumatic coma can range from 25% to 87%. If a non-traumatic unconscious state lasts for more than 6 hours, the 1-month mortality rate is 76%. The cause of the non-traumatic coma can heavily affect the final result. Overdosing on depressants, certain diseases that erode the protective coverings of nerve fibers, seizures, poisoning, or certain brain diseases usually have better outcomes if supportive care is given correctly. On the other hand, stroke, brain aneurysm, or loss of oxygen to the brain usually have poorer outcomes. Eye-related signs and motor function are reliable predictors of long-term outcomes.

Possible Complications When Diagnosed with Unconscious Patient

The reasons behind unconsciousness, how long it lasts, and the surrounding events can often impact the potential difficulties that a patient may face. Such issues could involve lasting harm to the brain, additional brain injury due to a lack of oxygen, a state of deep unconsciousness known as a coma, a lung infection caused by inhaling food or liquid referred to as aspiration pneumonia, and problems with bladder or bowel function. Other concerns may include skin sores, injuries from falls, infections related to catheters, malnutrition, and even death. Broken ribs as a result of performing CPR, limb weakness, changes in executive functions – the set of mental skills that help to get things done, changes in emotions and behaviour, imbalances in hormones regulated by the pituitary gland (a small bean-shaped gland in the brain), troubles with memory, or difficulties with vision, speech, and language can also occur.

Potential Complications:

Permanent brain damage
Secondary brain injury from a lack of oxygen
Coma
Aspiration pneumonia
Bladder or bowel dysfunction
Skin ulcers
Injuries from falls
Infections from catheters
Malnutrition
Death
Broken ribs from CPR
Limb weakness
Changes in executive functions
Emotional and behavioural changes
Pituitary hormonal imbalances
Memory difficulties
Visual, speech, and language difficulties

Preventing Unconscious Patient

Unconsciousness is a state like sleep where a person loses awareness of themselves and their surroundings. They do not respond to talking, touching, or even pain. This can be caused by several reasons such as damage to the brain due to stroke, bleeding, tumors, or head injuries. It can also be caused by seizures, low blood sugar levels, imbalances of body salts or electrolytes, or drug overdoses.

When someone becomes unconscious, doctors and nurses closely examine the person’s medical background and what medicines they have been taking. They check the person’s movements, responsiveness to sound and touch, and pupil reactions to light to help make a diagnosis. Tests such as brain scans using CT (a type of X-ray) or MRI (a special magnet-based scan), blood tests, and heart monitoring are usually done to investigate the cause of unconsciousness. They look for possible infections, low blood sugar levels, electrolyte imbalances, and even signs of a heart attack. If seizures are suspected, a test to measure the brain’s electrical activity (called an EEG) might be done. In some cases, a sample of the fluid around the brain and spinal cord might be taken using a needle placed in the lower back. This is to check for the presence of an infection in the brain covering termed meningitis.

The type of treatment and how long someone stays unconscious depends on what caused it. Some people might need a machine to help them breathe, medications to keep their blood pressure stable, and nutrition provided through a drip or a tube directly into the stomach.

Frequently asked questions

The prognosis for an unconscious patient can vary depending on several factors, including the cause of the unconsciousness, the severity of the brain injury, and individual patient characteristics. Some key points to note about prognosis for unconscious patients include: - The mortality rate for non-traumatic coma can range from 25% to 87%. - Patients who become unconscious from non-traumatic causes and do not recover quickly often have lower chances of a beneficial outcome compared to patients with traumatic brain injuries (TBIs). - Eye-related signs and motor function are reliable predictors of long-term outcomes.

Unconsciousness in a patient can be caused by various factors such as structural brain issues (e.g., stroke or traumatic brain injury), systemic issues (e.g., low blood sugar or cold body temperature), psychological issues (e.g., psychogenic unresponsiveness), drug overdose or poisoning, and changes in metabolism (e.g., hormone imbalances or acid-base imbalances).

Signs and symptoms of an unconscious patient can include the following: - Loss of consciousness: The patient is unresponsive and unaware of their surroundings. - Abnormal vital signs: Changes in heart rate, blood pressure, and respiratory rate may be observed. - Breathing abnormalities: Irregular or shallow breathing patterns may be present. - Skin abnormalities: The skin may appear pale, sweaty, or flushed. - Eye abnormalities: Certain eye findings can provide clues to the underlying cause, such as papilledema indicating increased brain pressure or Roth spots suggesting bacterial endocarditis. - Pupillary light reflex: A problem with the pupillary light reflex may indicate a lesion in the brainstem or mesial temporal structures being pushed down. - Medication history: Knowing the patient's medication can help identify potential causes of unconsciousness. - Recent sicknesses: Information about any recent illnesses can be helpful in determining the cause. - Timeline of consciousness loss: Understanding when the patient lost consciousness can provide important context. - Fractures and wounds: The presence of fractures and wounds may indicate trauma as the cause of unconsciousness. It is important to note that these signs and symptoms are not exhaustive, and a thorough medical evaluation is necessary to determine the underlying cause of unconsciousness in a patient.

The types of tests that may be needed for an unconscious patient include: - Vital sign monitoring (pulse, breathing, blood pressure, temperature) - Glasgow Coma Scale (GCS) or Full Outline of UnResponsiveness (FOUR) assessments to assess responsiveness - Eye examination using a funduscope to check for signs of damage - Neuroimaging techniques such as a CT scan of the brain - Serum tests and other diagnostic imaging tests - Lumbar puncture to collect fluid for testing - Electroencephalogram (EEG) to check for signs of seizures

The doctor needs to rule out the following conditions when diagnosing an unconscious patient: 1. Structural Causes: Stroke, traumatic brain injuries (TBIs), brain tumors, inflammation, venous thrombosis, hydrocephalus, locked-in syndrome, akinetic mutism, and different types of brain bleedings. 2. Systemic Causes: Low or high blood sugar, low or high sodium levels, high levels of calcium, seizures, systemic infections, meningitis, encephalitis, adrenal crisis, pituitary apoplexy with hormonal insufficiency, endocrine abnormalities, deadly form of hypothyroidism (myxedema coma), drug overdose, illicit drug use, neuroleptic malignant syndrome, excessive alcohol intake, liver disease, kidney disease, heavy metal poisoning, malaria, aspergillosis, herbicides, carbon monoxide poisoning, and anesthesia. 3. Psychogenic Causes: Mental health conditions, including catatonia, severe depression, conversion disorder, and malingering.

When treating an unconscious patient, there are potential complications and side effects that can arise. These include: - Permanent brain damage - Secondary brain injury from a lack of oxygen - Coma - Aspiration pneumonia - Bladder or bowel dysfunction - Skin ulcers - Injuries from falls - Infections from catheters - Malnutrition - Death - Broken ribs from CPR - Limb weakness - Changes in executive functions - Emotional and behavioral changes - Pituitary hormonal imbalances - Memory difficulties - Visual, speech, and language difficulties

A healthcare provider or a doctor should be consulted for an unconscious patient.

The range of death rates varies significantly; they can be anywhere between 25% to 87%.

When treating an unconscious patient, doctors typically start treatment before completing the diagnosis. The first step involves providing oxygen if the patient's oxygen levels are low or if they are not responding well to stimuli. Doctors may also administer fluids or medications to control blood pressure and check vital signs such as heart rate, breathing rate, temperature, and blood pressure. If the cause of unconsciousness is unclear, doctors may administer glucose and thiamine while waiting for lab test results. Specific antidotes may be given if a drug overdose is suspected, and measures may be taken to lower intracranial pressure and manage seizures. In cases of suspected infection, antibiotics or antiviral medication may be administered. Maintaining the right balance of fluids and electrolytes is important, as is controlling body temperature. If initial treatment does not result in improvement, more intensive care may be necessary.

An unconscious patient is someone who is in a deep state of unconsciousness and is unresponsive to stimuli, even if they are strongly stimulated. They cannot be woken up and their eyes remain closed.