UNCONSCIOUSNESS

DEFINITION

Unconsciousness is a state of loss of consciousness where the patient is not awake or not aware of self and environment.

ETIOLOGY

• Structural lesions in brain that causes pressure to the brain stem like cerebral edema, subdural or epidural hematoma.
• Disease in the organs like heart, liver, lungs and kidney.
• Poisoning alcohol and drugs consumption fluid and electrolyte imbalances.
• Seizures
• Infections like encephalitis and meningitis.
• Severe nutritional deficiencies
• Hypoglycemia
• Ischemia
• Syncope
• Anemia

PATHOPHYSIOLOGY

Any conditions that causes Cranial insult

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Damage to the brain & Nerve cells

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Cerebral Edema

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Increased ICP

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Compression of blood vessels

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Decreased cerebral blood flow

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Decreased Oxygen to the brain cells

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Death of brain cells

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Loss of consciousness

CLINICALMANIFESTATIONS

• Altered level of consciousness
• Coma
• Irregular breathing
• Altered pupillary reaction
• Visual changes
• Headache
• Aphasia
• Paralysis of the extremities
• Sensory motor deficits
• Tremors

DIAGNOSTIC EVALUATION

• Neurological examination:
  • Glasgow coma score to assess the level of Consciousness
  • sensory function tests to assess the vision, hearing, taste, smell & touch Sensation
  • Motor Function tests to assess the Muscle power
  • Cranial Nerve assessment to Monitor Cranial Nerve Function
  • Test for Reflexes to identify the Nerve Function
• CT/MRI: To identify structural lesions in brain
• Lumbar puncture with CSF Analysis To assess the presence of Meningeal or Cerebral infection/ tumors etc.
• Electroencephalogram (EEG): To identify seizure
• Liver function test like Bilirubin, Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), Lactate dehydrogenase (LDH) and Renal function test like Urea, creatinine & bicarbonate levels to identify metabolic disorders
• Complete blood count to Identify hemodynamic parameters
• Sr. Electrolytes to monitor the Renal Function
• Electrocardiogram (ECG) to monitor Cardiac Function
• Coagulation profile tests like Bleeding time (BT), Clotting time (CT), Prothrombin time (PT), Thrombin time (TT), Partial thromboplastin time (PTT) & D-dimer are deranged in case o brain Attack or stroke

MEDICAL MANAGEMENT

• Determine the level of consciousness
• Maintain Circulation, Airway & breathing (CAB)
• Insert Nasal or Oropharyngeal Airway
• Perform Suctioning of the Nasal & oral cavity in case of Secretions
• Start Oxygen therapy with oxygen mask or Endotracheal Intubation & Mechanical Ventilation, if client has problems with breathing
• Administer Inj. IV Glucose incase of hypoglycemia
• Fluid management is done to correct the fluid imbalance
• Correct electrolyte by KCL admn to correct potassium imbalances.
• Calcium gluconate is administered to correct calcium imbalances and bicarbonate (Hco3) is administered to correct acidosis
• Administer Inj. Thiamine to prevent encephalopathy
• Administer Osmotic Diuretics like Inj. Mannitol 20% and Inj. Lasix 20mg as prescribed to decrease Cerebral Edema
• Administer steroids and Barbiturates to decrease intra cranial pressure.
• Incase of fever administer Tab. Paracetamol and cold applications.
• Gastric Lavage is done incase of poisoning & Antidote Naloxone is administered to prevent the toxins to enter the Central Nervous system.
• Meet the Nutritional Needs of the client. Insert Nasogastric tube and feed the client around 100-200ml once every 2 hours, if oral feeds are not tolerated
• DVT Prophylaxis with TED stockings (Thromboembolic devices and (SCD)sequential compressive devices.
• Prevent pressure sores by providing back care and changing positions every 2 hourly and use of Alpha or water Mattresses
• Perform range of motion exercise to all extremities in order to prevent joint stiffness.
• Administer Blood transfusion after cross matching & Rh typing to treat anemia
• Meet the basic needs and bed side care of the client.

SURGICAL MANAGEMENT

Craniotomy with burr hole:

• Depending on the location of the pathological condition a craniotomy may be done in frontal, occipital, parietal, temporal bone.
• A set of burr holes is drilled and a saw is used to connect the holes to remove the bone flap by operating under microscope.
• After surgery the drains are placed to remove fluid and blood and the bone flap is wired and sutured

PREVENTION OF COMPLICATIONS

• Promote Nutrition by  initiating Ryles tube feeding
• Avoid Hyperglycemia by administer insulin
• Change the position every 2 hours once to prevent pressure sore.
• Provide range of motion exercise to aid in mobility.
• Eyes can be closed and taped to prevent corneal abrasions.
• Clear the airway to prevent aspiration
• Wear  anti-embolytic stockings to prevent DVT.