Case 3 Week 24Young patient in coma

PC• Young man (in twenties) – BIBA• Found unconscious in bed – dressed in jeans and t-shirt• Still comatosed • HPC• Last seen about 10pm last night by flatmate and well PMHx• Collateral: nil previous medical conditions

Q1   What are you going to do immediately?1. ABC, O2, Vital signs, GCS (Intubation and drug interfere with

GCS so should do GCS on admission)• GCS < 8 tube2. IV access• If hypotension volume expanders or vasopressors or both3. Blood test, urine test• FBC • U & E• Glucose• LFT• PT and PTT• Other mentioned in up to date: Ca, Mg, Phosphate, Creatinine,

Lactate, Osmolarity• ABG• Drug screen: opiates, benzo, barbiturates, salicylates, cocaine,

amphetamines, ethylene glycol, methanol

Further blood tests (if cause of coma remains unknown):• Adrenal and Thyroid• Blood cultures• Blood smear for thrombotic thrombocytopenic purpure• Carboxyhemoglobin for CO poisoning (eg. Pt found in burning

building or car)• Serum drug concentration for specific drugs

4. Recommended to give 25 g of dextrose whilst waiting for blood tests

5. Thiamine 100 mg should be given with or preceding glucose in pt who may be malnourished

6. While use of ‘coma cocktail’ (glucose, thiamine, naloxone, and flumazenil) has been promoted Systematic review found that reasonable to give glucose and thiamine but naloxone and flumazenil should only be used in suspected drug overdose

7. If suspected herniation syndrome on CT Mannitol (osmotic diuretic)

8. If hyperthermia antipyretics• Empirical Ab and Antiviral if meningitis or viral

encephalitis suspected9. Hypothermia neuroprotective effects in pt with cardiac

arrest• Only extreme (<33 C) should be treated10.If seizures Phenytoin• If no EEG and nonconvulsive seizures suspected

therapeutic trail of phenytoin or lorazepam is reasonable

O/ENo response to pain, no gag reflex – accepts Guedel airway without response.RR 14 , not cyanosed (oxygen saturation 99% on 8l/min oxygen) PR 110 bpmBP 100/60 mm Hg T 37oC BSL 4.9mmol/L (4 – 8)IV line inserted, infusion isotonic saline, bloods for FBC, ELFTs, blood alcohol and serum paracetamol

Q2   Outline Glasgow Coma Scale – what is the patient’s score?

• No response to pain 1• No eye opening 1• No verbal response 1• GCS = 3

Q3  Describe and justify what you should look for on examination?

1. Vital signs- Extreme HTN Intracerebral/cerebellar/brainstem haemorrhage- Hypotension shock, drugs- Hyperthermia infection, heat stroke, anticholinergic

intoxication

2. Ventilatory patterns combined with blood gas resp or metabolic acidosis or alkalosis

3. Cutaneous and mucosal abnormalities

4. Other: signs of trauma, eg. Dislocation ; CSF rhinorrhea; meningismus (note that meningeal signs are often absent in deep coma)

5. Exam lungs, heart, abdo6. Neuro exam (modified!!!) in comatose pt to determine

whether pathology is structural or metabolic (incl. drug effects and infection)

a. Level of consciousness– Arousability by noise and pain (pressing on supraorbital

nerve or angle of jaw, squeezing trapezius)– GCS

b. Motor response – Decorticate: lesion above red nucleus of midbrain

preserving rubrospinal tract (red nucleus activates the flexors)• Will see flexor on the arms

– Decerebrate: lesion below red nucleus of midbrain rubrospinal tract gone. Vestibulospinal predominate• Vestibulospinal mianly activate ipsilateral extensors• All 4 limbs extension

3. Brainstem reflexes: pupillary light, extraocular (if stationary while head is moved doll’s eyes effect. If spine fracture suspected, shoot cold water into ear after pt inclined 30 degrees has same effect as pt head turned to opposite side of injection, eye should move to ear of injection), and corneal reflexes– Also examine fundi papilloedema, Roth spots

(endocarditis, leukemia, vasculitides, diabetic retinopathy)

– Disruption in pupillary light reflex herniation or brainstem lesion• Usually spared in metabolic and toxic but certain

toxic syndromes can cause miosis or mydriasis• • 2 findings on exam for structural lesion

– Asymmetry between right and left response– Abnormal reflexes that point to specific areas within

the brain

Caloric Testing for Real!!!!http://www.youtube.com/watch?v=Vo00ZYOXDrQ&feature=related

Q4   What are the common causes of coma?

Most common cases of coma presenting to ED due to:• Trauma• Cerebrovascular disease• Intoxications• Metabolic derangements• Coma after cardiac arrest• Post ictal coma

Trigger 3• From further history, examination and investigations it is

established that the patient has attempted suicide with a cocktail of vodka, temazepam, oxazepam, paracetamol and dothiepin

Q5   What is your general management plan at this point?

After pt is stabilized decontamination* Activated charcoal is preferred Give antidotes- Benzodiazepines Flumazenil- Acetaminophen N-acetylcysteine- TCA Sodium bicarbonate

***!!! HOWEVER !!! Flumazenil is contraindicated in known or suspected TCA use as it may lower the seizure threshold can induce benzo-withdrawal seizures ***

Q6   Following appropriate medical treatment the patient makes a complete recovery.  What is the next step in management

Psychiatric evaluation* Determining risk of suicide completion or subsequent attempt* Identification of predisposing and precipitating factors that can be treated or modified* If at risk to himself and others: Involuntary under MHA