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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.
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
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.