Abstract

The acute presentation of an unconscious individual is a common scenario and it indicates a severe pathological insult. Aetiology may not be apparent at initial assessment and maximal use of available resources should be made to identify the cause. Initial management should be directed towards resuscitation and stabilisation of the individual, followed by further clinical assessment. The prevention of secondary brain injury is essential and so respiratory, circulatory and metabolic abnormalities should be treated aggressively. Early involvement of critical care physicians may be required. Detailed aspects of acute management and specific care of head injured, intoxicated and post-cardiac arrest patients is discussed.
[download-attachments container="div" style="list" display_icon="1" display_count="1" display__size="0"]

References

1. Oschatz E, Laggner AN: The unconscious patient; pathophysiology, Webb AR et al, editors: Oxford Textbook of Critical Care. Oxford, 1999, Oxford University Press; Chapter 7, section 2.1: 438
2. Bleck TP, Webb AR: The unconscious patient; causes and diagnosis, Webb AR et al, editors: Oxford Textbook of Critical Care. Oxford, 1999, Oxford University Press; Chapter 7, section 2.2: 440
3. Harrison, MJG: Coma, Weatherall DJ, Ledingham JGG, Warrell, editors: Oxford Textbook of Medicine. Oxford, 1996, Oxford University Press; Chapter 24, section 4.4: 3930
4. Venkatesh B: Disorders of consciousness, Bersten AD, Soni N, Oh TE editors: Oh’s Intensive Care Manual, ed. 5, Edinburgh, 2003, Butterworth Heinemann; Chapter 40: 469
5. Booth SA, Menon DK; Applied cerebrovascular physiology. Anaesthesia and Intensive Care Medicine 2001; 2 (8): p293-8
6. Booth SA, Menon DK; Pharmacological and pathological modulation of cerebrovascular physiology. Anaesthesia and Int Care Med 2001; 2(8): 299-302
7. Hoffman RS, Goldfrank LR; The poisoned patient with altered consciousness: controversies in the use of a ‘coma cocktail’. Journal of the American Medical Association 1995; 274(7): 562-9
8. Mokhlesi B et al; Adult toxicology in critical care. Part 1: general approach to the intoxicated patient. Chest 2003; 123(2): 577-592
9. Sprigings D, Chambers J: The unconscious patient, Sprigings D, Chambers J: Acute medicine. A practical guide to the management of medical emergencies, Oxford, 1990, Blackwell Scientific Publications; Chapter 6: 44
10. Barbaccia JJ, Williams JM; The acute management of head injury. Current Opinion in Anaesthesiology 2001; 14 (2): p227-231
11. Hayes M: Cerebral protection, Bersten AD, Soni N, Oh TE, editors: Oh’s Intensive Care Manual, ed. 5, Edinburgh, 2003, Butterworth Heinemann; Chapter 43: 505
12. Meredith TJ, Vale JA, Proudfoot AT: Poisoning; introduction and epidemiology, editors: Oxford Textbook of Medicine. Oxford, 1996, Oxford University Press; Chapter 8, section 1.1: 1043
13. Smith KM, Larive LL, Romanelli F. Club drugs: methylenedioxymethamphetamine, f lunitrazepam, ketamine hydrochloride, and gamma-hydroxybutyrate. American Journal of HealthSystem Pharmacists 2002; 59: 1067-1076
14. Abelsohn, A et al. Identifying and managing adverse environmental health effects: 6. Carbon monoxide poisoning. Canadian Medical Association Journal 2002; 166(13): 1685-1690
15. Shanti CM, Lucas CE. Cocaine and the critical care challenge. Critical Care Medicine 2003; 31(6): 1851-9
16. Wright RO, Lewander WJ, Woolf AD. Methemoglobinemia: etiology, pharmacology and clinical management. Annals of Emergency Medicine 1999; 34(5): 646-656
17. Safar P, Kochanek PM: Circulatory management; resuscitating and protecting the brain, Webb AR et al, editors: Oxford Textbook of Critical Care. Oxford, 1999, Oxford University Press; Chapter 1, section 2.4: 18
18. Lee RP, Morley P: Adult cardiopulmonary resuscitation, Bersten AD, Soni N, Oh TE, editors: Oh’s Intensive Care Manual, ed. 5, Edinburgh, 2003, Butterworth Heinemann; Chapter 15: 149
19. Young BG. Ethics in the intensive care unit with emphasis on medical futility in comatose survivors of cardiac arrest. Journal of Clinical Neurophysiology 2000; 17(5): 453-6
20. Mandl C, Kramer L, Oomanovits et al. Improved outcome prediction in unconscious cardiac arrest survivors with sensory evoked potentials compared with clinical assessment. Critical Care Medicine 2000; 28: 721-6