Scribd Logo
Upload

Welcome to Scribd!

  • 59 views

    Approach To The Comatose Patient

    Uploaded by

    steffiwp
    This document provides guidance on evaluating and managing a comatose patient. It outlines the key steps to take within the first hour, including assessing airway, breathing, circulation and performing a neurological exam. Causes of coma like hypoglycemia, opioid overdose, structural lesions and metabolic derangements are discussed. The case presented is of an unresponsive 64-year-old male who upon workup showed myoclonic jerks, enlarged reactive pupils and metabolic acidosis, leading to a diagnosis of tricyclic antidepressant toxicity. Communication with family and appropriate testing based on exam findings are also reviewed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Approach To The Comatose Patient

    Uploaded by

    steffiwp
    59 views29 pages
    This document provides guidance on evaluating and managing a comatose patient. It outlines the key steps to take within the first hour, including assessing airway, breathing, circulation and performing a neurological exam. Causes of coma like hypoglycemia, opioid overdose, structural lesions and metabolic derangements are discussed. The case presented is of an unresponsive 64-year-old male who upon workup showed myoclonic jerks, enlarged reactive pupils and metabolic acidosis, leading to a diagnosis of tricyclic antidepressant toxicity. Communication with family and appropriate testing based on exam findings are also reviewed.

    Original Title

    Approach to the comatose patient

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides guidance on evaluating and managing a comatose patient. It outlines the key steps to take within the first hour, including assessing airway, breathing, circulation and performing a neurological exam. Causes of coma like hypoglycemia, opioid overdose, structural lesions and metabolic derangements are discussed. The case presented is of an unresponsive 64-year-old male who upon workup showed myoclonic jerks, enlarged reactive pupils and metabolic acidosis, leading to a diagnosis of tricyclic antidepressant toxicity. Communication with family and appropriate testing based on exam findings are also reviewed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    59 views29 pages

    Approach To The Comatose Patient

    Uploaded by

    steffiwp
    This document provides guidance on evaluating and managing a comatose patient. It outlines the key steps to take within the first hour, including assessing airway, breathing, circulation and performing a neurological exam. Causes of coma like hypoglycemia, opioid overdose, structural lesions and metabolic derangements are discussed. The case presented is of an unresponsive 64-year-old male who upon workup showed myoclonic jerks, enlarged reactive pupils and metabolic acidosis, leading to a diagnosis of tricyclic antidepressant toxicity. Communication with family and appropriate testing based on exam findings are also reviewed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 29

    COMA

    Content: Rhonda S.Cadena, MD & Aarti Sarwal, MD


    Slides: Ryan Martin, MD
    ENLS Version 3.0

    Presenter: Your Name


    Conflicts
    • No conflicts of interest
    Comatose Patient

    Learning Objectives
    • Perform a neurological exam in a comatose
    patient
    • Assess airway and need for assisted
    ventilation
    • Establish a diagnosis for the cause of coma
    • Treat presumptively for the most likely cause
    of coma if indicated
    Coma – What is it?
    Arousal: wakefulness, eye opening
    Awareness: able to follow commands, content
    processing
    Checklist for the 1st hour
    ☐ Evaluate/treat circulation, airway, breathing and C-
    spine
    ☐ Exclude/treat hypoglycemia or opioid overdose
    ☐ Serum chemistries, ABG, urine toxicology screen

    ☐ Emergent cranial CT if structural or uncertain


    etiology
    ☐ Determine if coma etiology is structural or non-
    structural
    Approach to the Patient with Coma

    • Assess level of consciousness


    • IV access
    • Airway
    • Breathing
    • Circulation
    • C-spine immobilization
    Approach to the Patient with Coma

     Hypoglycemia
    ▪ Blood glucose < 70mg/dL (3.9mmol/L)
    ▪ 50ml of 50% dextrose
    ▪ Thiamine 100 mg IV before dextrose in
    patients at risk for nutritional deficiency
     Opioid Toxicity
    ▪ Naloxone 0.04-0.4mg IV repeated up to
    max dose of 4mg
    Case
    Unresponsive Patient

     64 year old male


     Unresponsive to voice
     Found in hotel room by
    housekeeping
     Last known well last night
     Brought to the ED by EMS
    Neurological Assessment

    1) Level of responsiveness
    2) Brainstem assessment
    3) Evaluation of motor responses,
    tone and reflexes
    4) Appraisal of breathing patterns

    Note any asymmetry in the


    examination
    Level of Responsiveness

    • Glascow Coma Scale (GCS)


    ▪ Eye opening
    ▪ Motor response
    ▪ Verbal response
    • Full Outline of UnResponsiveness Scale (FOUR)
    ▪ Eye opening
    ▪ Motor response
    ▪ Brainstem response
    ▪ Respiratory response
    Brainstem Assessment

    • Pupillary Response
    ▪ Pinpoint: raises concern of pontine damage
    ▪ Large, unreactive: midbrain damage, 3rd nerve compression
    • Corneal Reflex
    • Visual threat response
    • Eye movements
    ▪ Spontaneous
    ▪ Oculocephalic Reflex (Doll’s Eyes)
    ▪ Vestibulo-ocular Reflex (cold caloric testing)
    • Cough reflex
    • Gag reflex
    Motor Function

    • Spontaneous movement or to noxious stimuli


    • Posturing in structural & metabolic coma
    ▪ Flexor (decorticate)
    ▪ Extensor (decerebrate)
    • Muscle tone
    • Reflexes
    • Distinguish between purposeful and reflex activity
    Breathing

    • Breathing patterns may help localize


    • Neurogenic Hyperventilation
    ▪ Midbrain and Pons
    • Cluster (Biot’s) breathing
    ▪ Pons
    • Ataxic breathing
    ▪ Medulla
    Case
    Neurological Assessment
    • Vitals:
    • Afebrile
    • HR 160 bpm
    • BP 105/70 mmHg
    • RR 12 /min
    • SpO2 100%
    • GCS 3 (E1, V1, M1)
    • No evidence of trauma
    Case
    Neurological Assessment
    • Blood glucose normal
    • Pupils are symmetric, reactive and enlarged to
    8mm; eyes are dry
    • Motor tone normal
    • Myoclonic jerks are present
    • He is intubated and ventilated for airway
    protection
    Picture attributed
    to Nutschig at the
    English Language
    • Bladder is distended (>1000cc urine)
    Wikipedia
    • Wife is contacted over the phone
    Focused Presenting History and Past
    Medical History

    Valuable clues to the etiology of coma


    • Time course of unconsciousness
    ▪ Abrupt
    ▪ Gradual
    • PMH, PSH
    • Meds, toxin exposures
    • Social history
    Case

    PMH MEDS
    Coronary Artery Aspirin
    Disease
    DM Type 2 Metformin
    Depression Amitriptyline at night
    Desvenlafaxine daily
    Recommended STAT Labs
    LABS
    ☐ Bedside blood glucose, if not done
    ☐ Serum Chemistries
    ☐ Arterial blood gas
    ☐ CBC
    ☐ Toxicology studies:
    ☐ETOH
    ☐Urine toxicology screen
    ☐ Microbiology studies
    ☐ Consider co-oximetry
    Initial Formulation
    Causes of Coma
    Neurologic Causes Toxic Metabolic Causes

    Trauma (severe) Drug overdose


    Neurovascular (stroke) Metabolic
    endocrine
    electrolyte
    hepatic, renal
    hypercapnea, hypoxia
    CNS infection (encephalitis) Environmental toxins
    Neoplasm (primary, metastasis)
    Seizure/status epilepticus
    Neuroinflammatory
    Autoimmune encephalitis, ADEM
    Other: PRES, HIE
    Back to the Case

    Structural insult?
    (stroke/hemorrhage) Metabolic
    Hx CAD hx DM
    rapid onset hx depression
    Medication overdose?
    abnormal pupils
    motor exam & reflexes
    versus
    Brain Imaging

    Unclear cause or focal exam


    • Noncontrast head CT STAT
    • CT angiography (CTA) and CT
    perfusion (CTP)
    ▪ Concern for ischemic stroke
    • CT with contrast
    ▪ Concern for CNS infection
    Persistent Uncertainty

    Additional testing
    MRI
    Lumbar puncture
    Continuous EEG
    Case Conclusion

    • CT Head normal, EEG without seizures


    • Labs show metabolic acidosis
    • EKG shows widened QRS and prolonged QTc
    • Tricyclic antidepressant toxicity suspected
    • Treatment with sodium bicarbonate drip
    • Within 36 hours, his EKG changes resolved and he woke up
    • He admitted to overdosing his amitriptyline and
    desvenlafaxine
    Pediatric Considerations
    • ABC as in adults
    • Children < 5 yrs modified GCS
    • TBI and infection leading causes of coma
    • Septic shock is common presentation of meningitis in
    children
    • Other causes: hypoglycemia, diabetes, hypothermia,
    acid-base and electrolyte imbalances, seizures,
    intoxications
    • Stat neuroimaging if exam focal or unclear etiology
    Communication
    ☐ Clinical presentation
    ☐ Relevant past medical/surgical history
    ☐ Findings on neurological examination
    ☐ Relevant labs
    ☐ Brain imaging, LP, or EEG results if
    available
    ☐ Treatments administered so far
    Questions?

    You might also like