Approach to coma in EDRunal Shah

PGY1

MEM, KDAH

Case Scenario 43/Male brought to ED by Cardiac

ambulance at 11.00 am c/o unresponsiveness x 7.00 am A – Snoring sounds, B – breathing equal chest rise, RR 10/min C – cold periphery, BP- 170/90, P-110/min D – GCS E1,V2,M2 – Pupils 1.5mm sluggish

How will you evaluate ??

Definition COMA – Deep sleep like state from which

the patient cannot be aroused.

o Vegetative stateo Catatoniao Akinetic mutismo Locked in state

Pathophysiology Consciousness – Awareness of the self or surroundings

Cognition – Orientation + Judgment Arousal – Level of Consciousness (Fully aroused to Comatose)

ARAS – Anatomically located in Paramedian tegmental zone of dorsal midbrain – responsible for arousal and cortical activation

Cerebral cortex – contains Cognition centers – determine content of consciousness

Insult to cerebral cortex or brainstem can independently cause Coma; vulnerable to Metabolic derangements, Toxins, Mechanical Injury.

If ARAS is impaired, cerebral cortex cannot be aroused.

Differential Diagnosis Neurologic Infectious Metabolic Toxic Pulmonary, hypoxia Cardiovascular

EtiologyStructural

Trauma– SDH– EDH

– Cerebral Concussion-Contusion

Stroke Syndromes– Embolism

– Thrombosis– Hemorrhagic

Tumors Infections

Age related

Infant– Infection

– Trauma/ Abuse– Metabolic

Child– Toxic ingestion

Adolescent/ Young Adults– Toxic

– Recreational Drug– Trauma

Elderly– Meds/ OTC drugs

– Infection– Stroke

Approach in EDPrimary Survey

– Airway– Breathing– Circulation– Disability (GCS, Pupils, NIHSS)– Exposure

VitalsBlood glucoseBrief History of events (SAMPLE)Secondary Survey (Head to toe)

Primary Survey Airway:

Patent / Compromised ?

Intervene for Hypoxia / Obstruction / Dyspnea

Proper position / Head tilt- Chin lift / Jaw thrust

Oxygen Supplementation

Nasal Prongs, Face mask, Venturi mask, Non-rebreathing mask, Bag-Mask, ET intubation

OPA, NPAs

Primary Survey Breathing:

Equal chest rise? Use of accessory muscle

Air entry bilateral equal? Adventitious sounds – Crepts/ Rhonchi/ Stridor ?

Primary Survey Circulation:

Peripheries Cold/ Warm, Capillary Refill Time

Blood pressure

Pulse : Rate, Rhythm, Volume

Intravenous Access – Blood collection & Sugars IV fluids according to Blood sugars

Primary Survey Disability:

GCS (E V M)

Pupils – Size, ShapeReactivity to lightConjugate movements

NIHSS scoring

C-Spine immobilization in case of Trauma

History• Trauma• Cardiac arrest• Drug overdose/ ingestion• Neurological-

– Circumstances & rapidity– Antecedent symptoms – Confusion, weakness,

headache, fever, seizures, double vision,vomiting

– Use of Meds, Drugs and Alcohol– Chronic liver, kidney, heart, other medical disease

• Direct interrogation with Family members, bystanders, Ambulance staff/ paramedics

Brainstem Reflexes Pupillary signs

– Examine with bright diffuse light– Shape, size, reactivity– Anisocoria?

Ocular movements– Spontaneous movements?– Conjugate deviation– Doll’s eye– Ocular bobbing/ dipping

Respiratory pattern– Shallow slow regular breathing– Cheyne-Stokes– Kussmaul– Agonal gasp

Immediate Interventions Intravenous AccessOxygen supplementCardioscope monitoringBlood glucoseECGEmergent Head CT

Ancillary Testing Blood Glucose Arterial / Venous Blood gas Electrolytes Serum creatinine, BUN CBC Coagulation – PT, aPTT Thyroid profile Urine routine and Toxicology screening

Imaging Radiology

CT Brain Plain CT Brain + Neck Angiography MRI Brain + MRAngiography Chest X-Ray Ultrasound

_______________________________ ECG EEG

Algorithm

Disposition Depending on diagnosis, patient goes to

Intensive care unit (ICU) /Operation room (OR)

Hypoglycemia patient requires ED observation, and admission in ICU if Sugars are borderline or mentation doesn’t improve.

Thank You…

Ref:

Harrison's Principles of Internal Medicine,19E

Rosen's Emergency Medicine,8ed