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Case 3 Week 24

Case 3 Week 24. Young 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.

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Case 3 Week 24

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  1. Case 3 Week 24 Young patient in coma

  2. 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

  3. 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  tube 2. IV access • If hypotension  volume expanders or vasopressors or both 3. 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

  4. 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 • If suspected herniation syndrome on CT Mannitol (osmotic diuretic)

  5. 8. If hyperthermia  antipyretics • Empirical Ab and Antiviral if meningitis or viral encephalitis suspected 9. Hypothermia neuroprotective effects in pt with cardiac arrest • Only extreme (<33 C) should be treated 10. If seizures Phenytoin • If no EEG and nonconvulsive seizures suspected  therapeutic trail of phenytoin or lorazepam is reasonable

  6. O/E No response to pain, no gag reflex – accepts Guedelairway 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?

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

  8. 1. Vital signs • - Extreme HTN Intracerebral/cerebellar/brainstem haemorrhage • - Hypotension  shock, drugs • Hyperthermia  infection, heat stroke, anticholinergicintoxication • 2. Ventilatorypatterns  combined with blood gas resp or metabolic acidosis or alkalosis • 3. Cutaneousand mucosal abnormalities Q3  Describe and justify what you should look for on examination?

  9. 4. Other: signs of trauma, eg. Dislocation ; CSF rhinorrhea; meningismus (note that meningeal signs are often absent in deep coma) 5. Exam lungs, heart, abdo 6. 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 • Vestibulospinalmianly activate ipsilateral extensors • All 4 limbs extension

  10. 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

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

  12. Most common cases of coma presenting to ED due to: • Trauma • Cerebrovascular disease • Intoxications • Metabolic derangements • Coma after cardiac arrest • Post ictal coma Q4   What are the common causes of coma?

  13. 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 ***

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

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