coma 1st aid by dr.mohamed el-abiad

Loss Of Loss Of ConsciousnessConsciousness

Dr. Mohamed El-Abiad

Approach to the Comatose Patient

Initial Treatment

Circulation Airway Breathing ABC - identify and address life threatening

inadequacies Treat rapidly progressive metabolic disorders Evaluate for intracranial hypertension and

imminent herniation and treat


Management of the Comatose Patient

Circulation

Is patient in shock? Check pulses, heart rate, blood pressure, perfusionRemember hypotension is late sign of shock

Start treatment for shockDo not restrict fluids in comatose patient with

inadequate intravascular volume. Cardiac output and cerebral perfusion are much

more important than fluid restriction


Use isotonic solutions and blood, as indicated.

Do not use hypotonic solutions to treat shock, particularly patients with coma or possible cerebral edema

Identify life threatening hemorrhage and control it.


Circulation


Management of the Comatose Patient Airway

Evaluate -- is airway patent. Can patient move air without obstruction. Is there trauma or foreign body obstructing airway

Try chin lift to help open airway -- protect cervical spine

Place airway if indicated - nasal or oral airway, intubation, or surgical airway



Breathing

Evaluate - is patient moving adequate air, is respiratory rate appropriate, is gas exchange adequate, are breath sounds adequate and symmetrical

Must assure oxygenation and ventilation If intubated don’t forget to ventilate Identify and immediately treat problems -

pneumothorax, airway obstruction, etc..Dr. Mohamed El-Abiad

Glasgow Coma ScaleGlasgow Coma Scale

Three components. Score derived by adding the score for each component.

• Eye opening (4 points)• Verbal response (5points)• Best motor response (6 points)


Eye opening• 4 - spontaneous• 3 - to speech• 2 - to pain• 1 - none

Verbal Response• 5 - oriented• 4 - confused conversation• 3 - inappropriate words• 2 - incomprehensible sounds• 1 - none

Best Motor Response• 6 - obeys• 5 - localizes• 4 - withdraws• 3 - abnormal flexion• 2 - abnormal extension• 1 - none




Score > 13 …… Fully Consciousness

Score < 3 …… Deeply Comatosed

Between 3-13 …… Disturbed Consciousness


Management and Evaluation of the Comatose Patient

Practicalities

During ABC’s and Tests:– Have someone start IV and obtain labs

ABG’sToxin screens

– As soon as IV in and giveGlucose (D25, 2 - 4 cc per kilogram)Consider thiamin


Intra CranialIntra Cranial

CausesCauses

Extra CranialExtra Cranial


Pupil Size

Pupil Direction

Deviation Of Angle Of mouth

Salivation

Buccinator Muscle

Hypotonia

Positive Babainiski SignDr. Mohamed El-Abiad

Pulse

Pupil

Patient

Blood Pressure Dr. Mohamed El-Abiad

HypertensionHypertension


EdemaEdema

HemorrhageHemorrhageDr. Mohamed El-Abiad

Subdural HematomaSubdural Hematoma


Acute epidural hematoma and midline shiftAcute epidural hematoma and midline shift


Herniation syndromesHerniation syndromes


HypertensionHypertensionLasix

Capoten

Nitroglycerin


DiabeticDiabetic


Hypoglycemia (Low Blood Sugar)Hypoglycemia (Low Blood Sugar)

CAUSES: Too little food, too much insulin or diabetes medicine, or extra exercise.

ONSET: Sudden, may progress to insulin shock.BLOOD SUGAR: Below 70 mg/dL. Normal range: 70-115 mg/dL

WHAT CAN YOU DO?

Drink a cup of orange juice or milk or eat several hard candiesTest Blood sugarWithin 30 minutes after symptoms go away, eat a snack e.g. sandwich, and a glass of milkContact doctor if symptoms don't stop


Hyperglycemia (High Blood Sugar)Hyperglycemia (High Blood Sugar)

CAUSES: Too much food, too little insulin, illness or stress.

ONSET: Gradual, may progress to diabetic coma.

BLOOD SUGAR: Above 200 mg/dL.Normal range: 70-115 mg/dL

WHAT CAN YOU DO?Test blood sugarIf over 250mg/dL for several tests, CALL YOUR DOCTOR!


Diabetic ketoacidosisDiabetic ketoacidosis



Symptoms

Nausea and vomiting Fruity breath (breath odor)

Stomach pain

Deep, rapid breathing

Flushed face

Dry skin and mouth

Muscle stiffness or aching Headache Shortness of breath Decreased consciousness Decreased appetite Abdominal pain FatigueBreathing difficulty while lying downFrequent urination or thirst for a day or moreMental stupor that may progress to coma Dr. Mohamed El-Abiad

Testing for Diabetic KetoacidosisTesting for Diabetic Ketoacidosis

Ketone testing may be used in type 1 diabetes to screen for early ketoacidosis. The ketones test is done using a urine sample. Ketone testing is usually done at the following times:

•When the blood sugar is higher than 240 mg/dL •During an illness such as pneumonia, heart attack, or stroke •When nausea or vomiting occur •During pregnancy

Other tests that may be done to diagnose ketoacidosis include:

•Arterial blood gas •Blood glucose test •Blood pressure measurement •Amylase blood test •Potassium blood test


KetoacidosisKetoacidosis

Insulin

NaHCO3

IV Fluids


Hepatic EncephalopathyHepatic Encephalopathy


CausesCauses::

(1) Virus hepatitis(2) Cirrhosis of liver, (3) Biliary cirrhosis, (4) Toxic hepatitis, (5) Infantile cirrhosis of liver, (6) Hepato toxic drugs, (7) Carcinoma of liver, (8) Portal hypertension, (9) Toxic nitrogenous products are absorbed from the large gut, (10)Defective synthesis of urea in the liver, etc.


Triggered byTriggered by : :

•Dehydration•Eating too much protein•Electrolyte abnormalities (especially a decrease in potassium) from vomiting or taking diuretics•Bleeding from the intestines, stomach, or esophagus•Infections•Kidney problems•Low oxygen levels in the body•Shunt placement or complications (portosystemic shunt )•Surgery•Use of medications that suppress the central nervous system (such as barbiturates or benzodiazepine tranquilizers)


Signs and SymptomsSigns and Symptoms::

Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start.

)A (Stage of pre-coma

)1 (Alteration in behaviour.(2) Impairment of memory and other intellectual functions.(3) Confusion and even delirium.(4) Slurring of the speech.(5) Inversibn of sleep rhythm.(6) Convulsion—local or generalised.(7) Restlessness(8) Disorientation about space time and persons.(9) Flapping tremor in the outstretched hand and fingers, wrist and even in the shoulder (Bat’s wing tremor).


Signs and SymptomsSigns and Symptoms::

)B) Stage of coma

)1 (Patient is in deep coma,(2) Muscles are flaccid.(3) Planter may be extensor absent.(4) Deep reflexes absent. [Cerebral disturbance (encephalopathy)]


DiagnosisDiagnosis::

• Complete blood count or hematocrit to check for anemia• CT scan of the head • EEG• Liver function tests• Prothrombin time• Serum ammonia levels• Sodium level in the blood• Potassium level in the blood• creatinine to see how the kidneys are working

Signs of liver disease, such as:yellow skin eyes (jaundice) fluid collection in the abdomen (ascites)occasionally a musty odor to the breath and urine

Tests may include :


(1) Complete bed rest. (2) Diet should contain more carbohydrate and less protein. (3) Sedatives(4) Good food and polyvitamins may be effective. (5) Drugs—sedate cause of anxiety and treated(6) Gastrointestinal bleeding must be stopped (7) Infections, kidney failure, electrolyte abnormalities

(especially potassium) need to be treated. (8) Life support may be necessary to help with breathing

or blood circulation, particularly if the person is in a coma.(9) Lactulose may be given to prevent intestinal bacteria from

creating ammonia , and as a laxative to remove blood from the intestines. Neomycin may also be used to reduce ammonia production by intestinal bacteria.

(10) Medications containing ammonium (including certain antacids) should also be avoided.

TreatmentTreatment


ComplicationsComplications

Prognosis

Acute hepatic encephalopathy may be treatable. Chronic forms of the disorder often keep getting worse or continue to come back.

Both forms may result in irreversible coma and death. Approximately 80% (8 out of 10 patients) die if they go into a coma. Recovery and the risk of the conditionreturning vary from patient to patient.

•Brain herniation•Brain swelling•Increased risk of:

•Cardiovascular collapse•Kidney failure•Respiratory failure•Sepsis

•Permanent nervous system damage•Progressive, irreversible coma•Side effects of medications


Renal Failure

Earthy Looking

Puffiness of eyelid in the morning

Lower limb edema


coma 1st aid by dr.mohamed el-abiad

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