Mayo Clinic Flagler COMA Stroke Education Day May 3...
Transcript of Mayo Clinic Flagler COMA Stroke Education Day May 3...
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W David Freeman, MD
Professor of Neurology and Neurosurgery
No conflicts of interest or disclosures
Mayo Clinic Flagler Stroke Education Day
May 3rd 2019
COMA
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Approach to the Comatose Patient
Objectives • Perform a neurological
coma exam • Assess ABC’s • Differential Diagnosis of
coma • Management
Neurocrit Care. 2015 Dec;23 Suppl 2:S69-75. doi:
10.1007/s12028-015-0174-1.
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Coma – What is it?
Arousal: wakefulness, eye opening
Awareness: able to follow commands, content processing
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Checklist for the 1st hour ☐ Evaluate/treat ABC’s and C-spine
☐ Rule out/treat hypoglycemia or opioid overdose
☐ Obtain Serum chemistries, ABG, urine toxicology screen
☐ Obtain emergent cranial CT to evaluate for structural stroke causes
☐ Determine if coma etiology is structural or non-structural
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Approach to the Patient with Coma
Assess level of consciousness
IV access
Airway
Breathing
Circulation
C-spine immobilization
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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
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Case Unresponsive Patient 75 year old male
Unresponsive to voice
Found in hotel room by housekeeping
Last known well last night (10pm)
Brought to the ED by EMS
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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
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Level of Responsiveness (Coma scales)
• Eye opening
• Motor response
• Verbal response
Glascow Coma Scale (GCS)
• Eye opening
• Motor response
• Brainstem response
• Respiratory response
Full Outline of UnResponsiveness
Scale (FOUR)
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Brainstem Assessment
• Pinpoint: raises concern of pontine damage
• Large, unreactive: midbrain damage, 3rd nerve compression
Pupillary Response
Corneal Reflex
Visual threat response
• Spontaneous
• Oculocephalic Reflex (Doll’s Eyes)
• Vestibulo-ocular Reflex (cold caloric testing)
Eye movements
Cough reflex
Gag reflex
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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
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Breathing
Breathing patterns may help localize
• Midbrain and Pons Neurogenic Hyperventilation
• Pons Cluster breathing
• Medulla Ataxic (Biot’s) breathing
Cheyne-Strokes- Cerebrum , OSA, CHF
Arch Neurol. 2006 Oct;63(10):1487-90.
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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
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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
• Bladder is distended (>1000cc urine)
• Wife is contacted over the phone Picture attributed to Nutschig at the English Language Wikipedia
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Valuable clues to the etiology of coma
• Time course of unconsciousness • Abrupt • Gradual
• PMH, PSH • Meds, toxin exposures • Social history
Focused Presenting History and Past Medical History
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Case
PMH MEDS
Coronary Artery Disease Aspirin
DM Type 2 Metformin
Depression Amitriptyline at night Desvenlafaxine daily
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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
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Initial Formulation
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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
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Back to the Case
Structural insult? (stroke/hemorrhage)
Hx CAD
rapid onset
abnormal pupils
motor exam & reflexes
Metabolic hx DM hx depression Medication overdose?
versus
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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
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Persistent Uncertainty
Additional testing
MRI
Lumbar puncture
Continuous EEG
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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
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Handoff Checklist ☐ 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
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Questions?