altered level of consciousness
TRANSCRIPT
APPROACH
Immediate interventions
Differential diagnoses
Clinical clues to diagnoses
Best initial tests to clarify diagnosis
Diagnostic tests
Definitive Management
CASE 1
74 M from home
Witnessed fall with headstrike when going to bed last night
Now unresponsive
36.3C, HR 62, 155/80, RR 12, SaO2 92%, GCS 6 (M3V2E1), BSL 6
CLINICAL CLUES
Description of fall
Risk factors for bleed
Signs of head injury
Pupil responses
Localising neurology
DEFINITIVE MANAGEMENT
Severe head injury:
Protect airway
Lower ICP – ventilation, mannitol/hypertonic saline, surgery, reverse anticoagulation
Avoid extremes of BP
Protect from further injury – Head up, BSL/temp control, seizure prevention, feed
Aspiration pneumonia/pneumonitis:
ABs
Speech assessment
CASE 2
73 F lives alone
Found by daughter unconscious on floor at home
Recent complaints of abdominal pain and increasing lethargy
38.9C, HR 110, 81/40, RR 18, SaO2 88%, GCS 9 (M4V3E2), BSL HIGH
DIFFERENTIAL DIAGNOSES
DKA/HHS
Sepsis – multiple sources to consider: intra-abdo, chest
Intracranial event
Rhabdomyolysis / renal failure
CLINICAL CLUES
Collateral history
Past history – diabetes
Abdominal pain history
Recent infective features
DIAGNOSTIC TESTS
Source identification – CXR, MSU, abdominal imaging
Rhabdomyolysis, renal failure – CK, UEC, coags, FWT
Intracranial pathology – CT
DEFINITIVE MANAGEMENT
DKA/HHS:
Fluid resus and replacement, controlled BSL lowering, K+ supplementation
Sepsis:
early antibiotics, vasopressors, source control
Rhabdomyolysis:
aggressive IV fluids, forced diuresis (UO >100mL/hr), electrolyte management
Cholecystitis:
ABs, surgery, CT-guided drainage
Ischaemic gut:
surgery
CASE 3
19 F
Bought to ED by parents
Thin, agitated, confused
39C, HR 125, 152/97, RR 24, SaO2 100%, GCS 13 (M5V4E4), BSL 9
DIFFERENTIAL DIAGNOSES
CNS infection
Toxidrome
Endocrinopathy
Intracranial lesion
Environmental
Psychiatric disorder (+/– in combination with the above)
DIAGNOSTIC TESTS
CNS infection – CT/MRI, lumbar puncture
Toxidrome – generally clinical
Endocrinopathy – blood gas, biochemistry
Intracranial lesion – CT/MRI
Psychiatric disorder – clinical picture
LUMBAR PUNCTURE
Colour – mildly turbid
Opening pressure – 220 mm H2O
WCC – 400/mL
RCC – 10/mL
Protein – 1.2g/L (0.18 – 0.45g/L)
CSF glucose – 2.2mmol/L (2.5-3.5mmol/L)
Gram stain – no organisms seen
LUMBAR PUNCTURE
Colour – clear
Opening pressure – 170 mm H2O
WCC – 111/mL
RCC – 8/mL
Protein – 0.75g/L (0.18 – 0.45g/L)
CSF glucose – 3.0mmol/L (2.5-3.5mmol/L)
Gram stain – no organisms seen
DEFINITIVE MANAGEMENT CNS infection:
antibiotics/virals, steroids
Toxidrome:
cease agent, prevent seizures, supportive care
Endocrinopathy:
seek specialist advice
Intracranial lesion:
protect airway, lower ICP, avoid extremes of BP, protect from further injury
Environmental:
control temperature, supportive care, prevent complications
Psychiatric disorder:
determine location of treatment, need for sectioning, CAT review