Approach to the comatose patient Stephen Lo. Introduction Focus on developing a structured...
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Approach to the comatose patient
Stephen Lo
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Introduction
Focus on developing a structured approach to comaCan be also applied to exam questions
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Case50 year old polynesian lady presented with headache followed by
LOCHow would you assess and manage this patient?
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Investigations
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My approachInitial managementDifferential diagnosisInvestigationsManagement
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Initial steps: safety + ensure adequate resources
Ask for resourcesABC, basic resuscitation
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Assessment of airway, breathing, and circulation
Airway patencyAirway protection:
What is the GCS Is there protective reflexes presentWhat is the risk of aspirationAre there secretions
Rate and pattern of ventilation
Circulation: signs of shock, hypotension. Consider maintaining CPP.
In this case, I would put Blood sugar levels at the priority of the ABCs
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Differential diagnosisNeed to construct a list of differential diagnosis at this point.
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Approach to the diagnosisNeed a simple way of classifying causesIntracranialExtracranial
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Intracranial Consider surgical sieve or other pneumonics Need to include the key ones such as: bleed, stroke, infection, trauma, Seizures, rarer causes such as tumours, autoimmune, vasculitis, PRES context specific differentials such as vasospasm, hydocephalus in SAH
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Extracranial These are generally metabolic in nature. Again, have a sieve that you are familiar with, but need to include the
most common ones including:
Drugs: direct effect, indirect effects
Acid base
Hypoxia/hypercarbic
Temperature
Organ function: Kidney and liver
Nutritional
Electrolyte disturbance
Endocrine
Sepsis
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Mimics of comaSevere peripheral neuropathy
Guillain Barre syndromeBotulismCritical illness neuropathy
Locked in syndromeAkinetic mutism
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AssessmentHistory and examination to rule out or in your differentialsCatagorize into three broad categories based on patient’s signsComa with focal signs: Suggests an intracranial event
Coma with meningism: Suggests meningitis, SAH
Coma without signs: Suggests a very diffuse intracranial lesion or an extracranial cause
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Investigations Consider all your options Systemic investigations CT head Lumbar puncture: MCS, PCR, antibodies CT angiogram EEG MRI SSEPs Cerebral angiogram
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What’s your management now?Medical managementSpecific managementPosition of patient, CO2 control, BP control, Osmotherapy, sedation,
sugar, seizure control, temperatureGeneral managementInterventionsRadiological interventionsSurgical management
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Case 249 yo male thai chef that was found collapsed at home, brought
in by ambulance.How would you manage this patient?
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AssessmentABC: Noisy breathingGCS:
E1V2M5Sats: 84 % on 6LBP 190/80, HR 90/min
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Further clinical assessmentRight side movement less than leftPupils equal and reactive
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Investigations
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Finding underlying causesThromboembolic
Consider source of clotBleeding
Is there an underlying abnormalityInfection
Are there underlying structural abnormality or immunosuppressionEpilepsy
Adult onset always need to consider cause
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Further investigationsASD on echoParadoxical embolus and therefore infarct
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Other learning pointsThat an extensive unilateral lesion can also cause reduced LOC