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    1c - Approach To Comatose Patients (Slides)

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    El Len
    The document provides guidance on evaluating and managing patients presenting with coma. It begins with an overview of coma and levels of consciousness. It then outlines a checklist for the initial hour of evaluation and management, including assessing ABCs, looking for reversible causes of coma like hypoglycemia, and obtaining imaging. The document reviews performing a focused neurological exam and assessing brainstem reflexes. It provides considerations on specific patient presentations and formulating initial working diagnoses and management plans.

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    1c - Approach To Comatose Patients (Slides)

    Uploaded by

    El Len
    78 views42 pages
    The document provides guidance on evaluating and managing patients presenting with coma. It begins with an overview of coma and levels of consciousness. It then outlines a checklist for the initial hour of evaluation and management, including assessing ABCs, looking for reversible causes of coma like hypoglycemia, and obtaining imaging. The document reviews performing a focused neurological exam and assessing brainstem reflexes. It provides considerations on specific patient presentations and formulating initial working diagnoses and management plans.

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    1c - Approach to comatose patients (slides)

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    The document provides guidance on evaluating and managing patients presenting with coma. It begins with an overview of coma and levels of consciousness. It then outlines a checklist for the initial hour of evaluation and management, including assessing ABCs, looking for reversible causes of coma like hypoglycemia, and obtaining imaging. The document reviews performing a focused neurological exam and assessing brainstem reflexes. It provides considerations on specific patient presentations and formulating initial working diagnoses and management plans.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    78 views42 pages

    1c - Approach To Comatose Patients (Slides)

    Uploaded by

    El Len
    The document provides guidance on evaluating and managing patients presenting with coma. It begins with an overview of coma and levels of consciousness. It then outlines a checklist for the initial hour of evaluation and management, including assessing ABCs, looking for reversible causes of coma like hypoglycemia, and obtaining imaging. The document reviews performing a focused neurological exam and assessing brainstem reflexes. It provides considerations on specific patient presentations and formulating initial working diagnoses and management plans.

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    of 42

    ENLS Version 4.

    0
    Approach to the Patient with Coma
    Content: Aarti Sarwal, MD; Sara Stern-Nezer, MD, MPH; Deborah S. Tran
    DNP, RN, CNRN, SCRN, NE-BC
    Slides: George A. Lopez, MD PhD
    Presenter:
    Your name
    Your institution

    Conflicts:
    No conflicts
    Editors’ Note: Global Considerations
    The intent of the editors, authors, and reviewers of this ENLS topic was not to
    address all the variations in international practice for the different diseases. We
    have discussed major practice variances (e.g., the availability of diagnostic
    testing, or the type of medications used) and encourage learners to use the
    ENLS algorithms as a framework on which any relevant local practice
    guidelines can be incorporated.
    The 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
    What is coma?

    Arousal: wakefulness, eye opening

    Awareness: able to follow commands, content


    processing
    Checklist for the 1st hour
    ☐ Evaluate/treat circulation, airway, breathing and cervical-spine

    ☐ Exclude/treat hypoglycemia or opioid/benzodiazepine overdose

    ☐ Serum chemistries, ABG, urine toxicology screen

    ☐ Emergent cranial CT (and CT-angio brain if appropriate) to


    determine if coma etiology is structural or vascular in etiology
    Approach to the Patient with Coma
    • Assess level of consciousness
    • Airway
    • Breathing
    • Circulation
    • Cervical-spine immobilization
    • IV/IO access
    Prehospital Checklist and Handoff
    • Airway, breathing, ventilation issues
    • GCS, pupils, and vital signs on presentation
    • IV or IO access, site and patency (IV)
    • Ruled out hypoglycemia
    • History from bystanders, witnesses, contextual or
    environmental observations (pill bottles, signs of trauma or
    seizure activity)
    • Medications administered, dose and response (naloxone,
    dextrose etc.)
    • Time when patient was last seen normal
    • Prodromal symptoms when last seen
    Approach to the Patient with Coma

    • Level of responsiveness
    • Assess for brainstem reflexes
    • Evaluation of motor responses,
    tone and reflexes
    • Note any asymmetry in the exam
    • Appraisal of breathing patterns
    Level of Responsiveness
    • Glasgow Coma Scale (GCS)
    ▪ Eye response (4 points)
    ▪ Verbal response (5 points)
    ▪ Motor response (6 points)
    • 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
    Pupillary Responses
    Pupillary change Possible etiologies/localization
    Pinpoint pupil Opioids
    Cholinergic intoxication
    Pontine damage (interrupts descending sympathetic pathways)
    Dilated, non-reactive pupils Cerebral anoxia, global
    Barbiturates
    Atropine
    Hypothermia
    Brain death
    Dilated, reactive pupils Pretectal lesions
    Stimulants (cocaine, methamphetamine), hallucinogens including
    PCP/LSD
    Anisocoria (pupillary 3rd nerve compression from uncal herniation
    asymmetry) Localized drug effect (e.g. ipratropium, tropicamide)
    Mid-position, fixed or irregular Midbrain lesion
    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 Pattern
    • Breathing patterns may help localize
    • Neurogenic hyperventilation
    ▪ Midbrain and pons
    • Cluster breathing
    ▪ Pons
    • Ataxic breathing
    ▪ Medulla
    Respiratory pattern Pattern Localization
    Global/metabolic encephalopathy
    Cheyne-Stokes
    Impaired forebrain or diencephalon
    Central neurogenic Metabolic encephalopathy
    hyperventilation High brainstem tumors (rare)

    Apneusis Bilateral pontine lesions

    Cluster
    breathing/ataxic Pontomedullary junction lesions
    breathing
    Lesions affecting ventrolateral medulla bilaterally
    Apnea
    (ventral respiratory group)
    Approach to the Patient with Coma
    • D50 (Dextrose 50%) IV if
    glucose < 70 mg/dL
    • Thiamine 100 mg IV before
    dextrose, in at risk patients
    • Administer naloxone if opiate
    overdose is concern
    ▪ IV, IM, IO, Sub-Q, ETT, Nasal
    Approach to the Patient with Coma

    • Head CT to assess for


    structural etiologies
    • Consider CTA for possible
    vascular cause
    ▪ Basilar thrombosis
    Approach to the Patient with Coma

    • Historical account
    • Comorbidities
    • Medications
    • Exposures
    Focused Presenting History and Past
    Medical History
    Valuable clues to the etiology of coma:
    • Time course of unconsciousness
    ▪ Abrupt
    ▪ Gradual
    • PMH, PSH
    • Social history
    Case: Unresponsive Patient

     60-year-old male
     Unresponsive to voice
     Found in hotel room by
    housekeeper
     Last known well night before
     Brought to the ED by EMS
    Case: Unresponsive Patient
    • Vitals:
    ▪ Hypothermic, T 34ºC
    ▪ HR 60 bpm
    ▪ BP 185/95 mmHg
    ▪ RR 10 /min
    ▪ SpO2 92%
    • GCS 3 (E1, V1, M1)
    Case : Unresponsive Patient
    What is the next step?

    A. Treat the elevated BP with nicardipine drip


    B. Assess ABCs
    C. STAT head CT
    D. Apply warming blankets to treat hypothermia
    Case : Unresponsive Patient
    What is the next step?

    A. Treat the elevated BP with nicardipine drip


    B. Assess ABCs
    C. STAT head CT
    D. Apply warming blankets to treat hypothermia
    Case: Neurological Assessment

    • Eyes closed, gaze disconjugate, OCR


    present
    • Pupils are symmetric, reactive and
    enlarged
    • No response to pain, motor tone
    diminished, no DTRs
    • Wife is contacted over the phone
    Case
    • ABCs assessed
    • Patient was intubated with concern for
    unknown cervical spine stability and
    possible elevated ICP
    • Labs sent
    Case
    PMH MEDS
    Coronary Artery Dz Aspirin
    DVT Apixaban
    DM Type 2 Metformin
    Amitriptyline at night
    Depression
    Desvenlafaxine daily

    Pharmacy contacted for possible emergent need of


    PCC as patient on apixaban
    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
    hypercapnia, 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
    • Abnormal pupils Medication overdose?
    • Motor exam & reflexes versus • Opioids
    Case

    What is the next step?


    A. Brain MRI
    B. Naloxone 0.4 mg IV, then head CT
    C. Hyperventilate patient
    D. Head CT
    Case

    What is the next step?


    A. Brain MRI
    B. Naloxone 0.4 mg IV, then head CT
    C. Hyperventilate patient
    D. Head CT
    Brain Imaging

    Unclear cause or focal exam


    • Non-contrast head CT STAT
    • CT angiography (CTA) and CT
    perfusion (CTP)
    ▪ Concern for ischemic stroke
    • CT with contrast
    ▪ Concern for CNS infection
    Case Conclusion

    • CT head with diffuse intraventricular hemorrhage and


    hydrocephalus
    • Pharmacy notified for urgent need and dosing of PCC
    • Neurosurgery consulted for emergent EVD
    • Patient hyperventilated until EVD placed
    • Mannitol infused
    Persistent Uncertainty?

    Additional testing
    • MRI
    • Lumbar Puncture
    • Continuous EEG
    Pediatric Considerations
    • ABCs 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
    Clinical Pearls
    • Key findings on the neurological examination of comatose patients can
    identify changes to suggest toxic syndromes that can lead to the rapid
    treatment of coma.
    • Suspect basilar thrombosis in comatose patients with the degree of
    coma out of proportion to imaging findings or metabolic
    derangements/intoxication; early identification and revascularization is
    key to improve outcome.
    • Elevated ICP can be seen in a variety of processes and cannot be
    excluded by imaging alone.
    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?

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