CLINICAL EVALUATION OF AN UNCONSCIOUS PATIENT

CLINICAL EVALUATION OF AN UNCONSCIOUS PATIENT- NEUROLOGICAL VERSUS NON-NEUROLOGICAL

Neurologists and internists are commonly called in to evaluate an unconscious patient, most often in an emergency room or in ICU. There are a large number of causes of unconsciousness, which can be broadly classified into neurological and non-neurological. 

 Common examples of neurological causes of unconscious state are:

 1. Brain stroke-infarct or hemorrhage; CVST,
2. Brain tumor,
3. Head injury,
4. CNS infection- encephalitis, meningitis,
5. Seizures,
6. Demyelinating illnesses- ADEM, acute MS (rare).

 Common examples of non-neurological causes of unconscious state:

 1. Metabolic derangements- high or low sugar, sodium, calcium, etc
2. Renal or hepatic failure,
3. Severe hypoxia or hypercapnia,
4. Hypotension & shock,
5. Drug-induced (sedatives, hypnotics) & poisoning
6. Psychogenic. 

 Clinical clues favouring a neurological cause of depressed consciousness level:

 1. History of focal seizures- Focal seizures point to a lesion in the contralateral cerebral hemisphere. Metabolic derangements usually cause generalised seizure (exception being hyperglycaemia, which can cause focal seizures),
2. History of focal neurological deficits, such as numbness or weakness on one half of body, asymmetry of reflexes
3. Presence of meningeal signs would suggest meningitis
4. Anisocoria- unequal pupils suggest a brain lesion. 

 It would be interesting to note that in patients without an obvious cause of coma, about 60-65% turn out to be non-neurological causes (medical or metabolic causes), and only 35-40% are found to have a neurological cause.

 Investigations to determine a neurological cause of coma:

 1. BRAIN imaging- CT or MRI brain can detect infarct, hemorrhage, tumor, abscess or demyelinating illness affecting the brain.
2. EEG- can help in detecting seizures. Sometimes, seizures are not very obvious. They may be subtle such as blinking of eyelids, or occasional muscle twitched. As patients are covered with blankets in ICU, these minor seizures may be missed. In a patient without an obvious cause of reduced consciousness, one should carefully look for these minor seizures. 
3. Lumbar puncture- can help in confirming or excluding a CNS infection. 

 Dr Sudhir Kumar MD DM 
Consultant Neurologist,
Apollo Hospitals, Hyderabad
drsudhirkumar@yahoo.com
04023607777/60601066
https://www.facebook.com/bestneurologist

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