MANAGEMENT OF MANAGEMENT OF UNCONSCIOUS UNCONSCIOUS
PATIENTPATIENT
DR. B. PRAKASH.DR. B. PRAKASH.Prof. M.B. PRANESHProf. M.B. PRANESH
DEPT. OF NEUROLOGYDEPT. OF NEUROLOGYKG HOSPITAL AND POSTGRADUATE KG HOSPITAL AND POSTGRADUATE
INSTITUTE, INSTITUTE, COIMBATORE – INDIACOIMBATORE – INDIA
INTRODUCTIONINTRODUCTION
Unconscious patient makes everybody Unconscious patient makes everybody
anxiousanxious
Requires structured way of approachRequires structured way of approach
Should act Urgently / Appropriately / Should act Urgently / Appropriately /
AccuratelyAccurately
Conscious> Drowsy> Unconscious> ?Conscious> Drowsy> Unconscious> ?
Death / Permanent Brain DamageDeath / Permanent Brain Damage
STAGES OF CONSCIOUSNESSSTAGES OF CONSCIOUSNESSConscious: Awareness of self and surroundings.Conscious: Awareness of self and surroundings.Clouding of Consciousness: Reduced attention Clouding of Consciousness: Reduced attention span with irritability.span with irritability.Confusion: Mild lowering of consciousness.Confusion: Mild lowering of consciousness.Lethargy : Drowsy but arousable.Lethargy : Drowsy but arousable.Obtundation: Drowsy, slow reaction, gives Obtundation: Drowsy, slow reaction, gives appropriate answers, back asleep on leaving appropriate answers, back asleep on leaving alone.alone.Stupor: Roused by vigorous repetitive stimuli, Stupor: Roused by vigorous repetitive stimuli, moans without proper answering.moans without proper answering.Light coma: Unarousable, disorganized primitive Light coma: Unarousable, disorganized primitive motor responses.motor responses.Deep Coma: Absence of response to most painful Deep Coma: Absence of response to most painful stimuli.stimuli.
Eye opening 4 Spontaneous3 To speech2 To pain1 NoneBest motor response6 Obeying5 Localizing pain4 Withdrawal3 Abnormal flexing2 Extensor response1 None
GLASGOW COMA SCALE
Best verbal response 5 Oriented4 Confused conversation3 Inappropriate words2 Incomprehensible sounds1 None
USED MOSTLY FOR HEAD INJURY
PATIENTS RATHER THAN STROKE
(HEMIPLEGIA,APHASIA)
AlgorhythmAlgorhythmCOMA
Airway/?IntubateIV LineCFCDTests-EmeHistory-Eme
CBC, ESRSugar,RFTABG,LytesCXR,ECGCa,Mg,Toxic Scr’n
TRAUMA
CT Scan
No Trauma
Neu.Surg
Stiff Neck CT Scan
Normal SAH
LP
Meningitis
Toxin
Alc->Thiamine 100mg / 50% Dextose 50 ml
Opiate -> Inj.Naloxone 0.4-0.8mg IV
BenzDia ->Inj.Flumazenil 0.2-1 mg IV
Others -> Stomach wash / Antidote / Sympt
Supple
CNS Exam
Normal Lateralising
Metabolic CT Scan
SELECTIVE HISTORY TAKINGSELECTIVE HISTORY TAKING
Friend /Relative /ObserverFriend /Relative /Observer
When was he Last seen?When was he Last seen?
How was he discovered?How was he discovered?
What is the mode & What is the mode &
evolution of Coma ?evolution of Coma ?
What are the past Illness?What are the past Illness?
What drugs he is on?What drugs he is on?
Is any past mental history?Is any past mental history?
TraumaTrauma
Drug / ToxinsDrug / Toxins
Head acheHead ache
VomitingVomiting
Seizures Seizures
GiddinessGiddiness
FeverFever
Chest painChest pain
SELECTIVE EXAMINATIONSELECTIVE EXAMINATION
VITAL SIGNS:VITAL SIGNS:
HTN – Structural /HT.EHTN – Structural /HT.E
Hypo – ShockHypo – Shock
SKINSKIN::
Trauma / Needle MarksTrauma / Needle Marks
Rashes / Cherry rednessRashes / Cherry redness
JaundiceJaundice
BREATH:BREATH:
Alcohol /AcetoneAlcohol /Acetone
Fetor HepaticusFetor Hepaticus
HEADHEAD
Hematoma/#/Lacer’nsHematoma/#/Lacer’ns
ENT:ENT:
CSF otorrhea/RhinorrheaCSF otorrhea/Rhinorrhea
HemotympanumHemotympanum
Tongue BitingTongue Biting
NECK:NECK:
Do not Move if injuredDo not Move if injured
Neck Stiffness Neck Stiffness (Meningitis / SAH)(Meningitis / SAH)
Gen. Phy. ExamGen. Phy. ExamFever: Syst infection / Meningitis / EncephalitisFever: Syst infection / Meningitis / Encephalitis
Hyperthermia: Heat stroke / Anticholinergic intoxcn.Hyperthermia: Heat stroke / Anticholinergic intoxcn.
Hypothermia : Cold exp / Alcohol / Barb /Phenoth’zHypothermia : Cold exp / Alcohol / Barb /Phenoth’z
Sedative/ HypoSedative/ HypoGlycemia/ HypoThyroid/ Per.cir.FailGlycemia/ HypoThyroid/ Per.cir.Fail
Tachypnea : Acidosis / PneumoniaTachypnea : Acidosis / Pneumonia
Aberrant Respiratory Patterns: BS disordersAberrant Respiratory Patterns: BS disorders
Marked HTN : HT.E / SAH / ICP / Head injuryMarked HTN : HT.E / SAH / ICP / Head injury
Hypotension : Alcohol / Barb / Int.bleed / AMI / Hypotension : Alcohol / Barb / Int.bleed / AMI / Sepsis / HypoThyroidism / Addison’s crisisSepsis / HypoThyroidism / Addison’s crisis
Petechiae: TTP/ Meningococcemia/ Bld’g DiathesisPetechiae: TTP/ Meningococcemia/ Bld’g Diathesis
NEUROLOGIC EXAMINATIONNEUROLOGIC EXAMINATION
1. Gen. Appearance1. Gen. Appearance
2. Level of Cons’ss2. Level of Cons’ss
3. Respiration3. Respiration
4. Fields4. Fields
5. Fundi5. Fundi
6. Corneal Reflex6. Corneal Reflex
1. To asses the Depth of COMA
2. To localize/Lateralize the lesion
7.Gag Reflex7.Gag Reflex
8.Pupils8.Pupils
9.Ocular Movements9.Ocular Movements
10.Motor Response10.Motor Response
11.Sensory Resp’se11.Sensory Resp’se
12.Reflexes12.Reflexes
NEU.EXAM-1.GEN.APPEAR’CENEU.EXAM-1.GEN.APPEAR’CE
Open Eyelids / Slack Jaw – Deep ComaOpen Eyelids / Slack Jaw – Deep Coma
Head & Gaze deviation – Ipsi.Hemi.LesionHead & Gaze deviation – Ipsi.Hemi.Lesion
Myoclonus –BS Lesion / MetabolicMyoclonus –BS Lesion / Metabolic
Focal Seizures – Contra.Lesion / HyperglycemiaFocal Seizures – Contra.Lesion / Hyperglycemia
NEU.EXAM- 2.LEVEL OF CONS.NEU.EXAM- 2.LEVEL OF CONS.
Document the response to specific StimulusDocument the response to specific Stimulus
Quantify with Glasgow Coma ScaleQuantify with Glasgow Coma Scale
NEU.EXAM- 3.RESPIRATION.NEU.EXAM- 3.RESPIRATION.Depressed – Any deep ComaDepressed – Any deep ComaChyne-stokes – Bihemisp / MetabolicChyne-stokes – Bihemisp / MetabolicHypervent’n – Met.Aci/ Hep.Enc/ BS les/ Coning Hypervent’n – Met.Aci/ Hep.Enc/ BS les/ Coning Apneustic – Pontine DamageApneustic – Pontine DamageCluster – Pontine/ Cerebellar damageCluster – Pontine/ Cerebellar damageAtaxic (Biot’s) – Medullary LesionAtaxic (Biot’s) – Medullary Lesion
NEUROLOGIC EXAMINATIONNEUROLOGIC EXAMINATION
4.Fields – By Menace Reflex4.Fields – By Menace Reflex5.Fundii –Papilledema - >12 hrs of 5.Fundii –Papilledema - >12 hrs of ↑ ICT↑ ICT Subhyloid H’ge – Asst’d č SAHSubhyloid H’ge – Asst’d č SAH6.Corneal Reflex – Aff: CrV / Eff: CrVII6.Corneal Reflex – Aff: CrV / Eff: CrVII7.Gag Reflex – Absent in BS Les / Deep coma7.Gag Reflex – Absent in BS Les / Deep coma11.Sensory Response – Lateralizing Sensory 11.Sensory Response – Lateralizing Sensory
LossLoss12.Deep T.Reflex – Helps in Lateralizing12.Deep T.Reflex – Helps in Lateralizing13.Plantar Reflex -- Helps in Lateralizing13.Plantar Reflex -- Helps in Lateralizing -- -- ↑ ↑↑ ↑ Structural / Metabolic Structural / Metabolic
1.1. Symmetrical Reacting pupils – intact midbrainSymmetrical Reacting pupils – intact midbrain
2.2. Normal pupils + Absent Dolls – Metabolic / Sedatives Normal pupils + Absent Dolls – Metabolic / Sedatives
3.3. Fixed Mid position pupil – Focal Midbrain LesionFixed Mid position pupil – Focal Midbrain Lesion
4.4. Pinpoint Reactive – Pontine Damage / Opiate / OPC / Pinpoint Reactive – Pontine Damage / Opiate / OPC / Hydrocephalus / Thalamic Hemorrhage Hydrocephalus / Thalamic Hemorrhage
5.5. Unil / Dil / Fixed – Uncal Herniation - same/oppositeUnil / Dil / Fixed – Uncal Herniation - same/opposite
6.6. Bil / Dil / Fixed – Central Herniation / Hypoxia / Atropine Bil / Dil / Fixed – Central Herniation / Hypoxia / Atropine or Barbiturate Poisoning / Mydriaticsor Barbiturate Poisoning / Mydriatics
7.7. Eccentric oval - Early midbrain / III n CompressionEccentric oval - Early midbrain / III n Compression
8.8. Unil / Small (Horner) – Large Cerebral Hemorrhage Unil / Small (Horner) – Large Cerebral Hemorrhage Affecting ThalamusAffecting Thalamus
NEU.EXAM- 8.PUPILS.NEU.EXAM- 8.PUPILS.
Frontal Eye fields drive horiz. Gaze to opp.sideFrontal Eye fields drive horiz. Gaze to opp.side
Pontine Gaze Centres drive gaze to same sidePontine Gaze Centres drive gaze to same side
Midbrain tegmentum & Lower diencephalon Midbrain tegmentum & Lower diencephalon mediates vertical gaze movementsmediates vertical gaze movements
Oculocephalic & Oculovestibular Reflexes act Oculocephalic & Oculovestibular Reflexes act via semicircular canals / CrVIII / Vestibular and via semicircular canals / CrVIII / Vestibular and 3,4&63,4&6thth N Nuclei -- in eliciting gaze movements N Nuclei -- in eliciting gaze movements in comatose patientsin comatose patients
Normal gaze indicate Intact Cr III – VIII (MB & Normal gaze indicate Intact Cr III – VIII (MB & PONS)PONS)
NEU.EXAM- 9.Ocular Movements.NEU.EXAM- 9.Ocular Movements.
(A) POSITION OF THE EYES AT REST :(A) POSITION OF THE EYES AT REST :1.1. Gaze away from Hemi paresis – Contra lateral Hemispherical lesionGaze away from Hemi paresis – Contra lateral Hemispherical lesion
2.2. Gaze towards Hemi paresis – Contra lateral Pontine Lesion / Contra Gaze towards Hemi paresis – Contra lateral Pontine Lesion / Contra lateral Seizure Activity lateral Seizure Activity
3.3. Forced down gaze – Mid Brain Tectal / Thalamic LesionForced down gaze – Mid Brain Tectal / Thalamic Lesion
4.4. Slow roving gaze – Bihemisperical LesionSlow roving gaze – Bihemisperical Lesion
5.5. Ocular bob (Slow upward Brisk Downward & Loss of Horizontal eye Ocular bob (Slow upward Brisk Downward & Loss of Horizontal eye movements) – Bil. Pontine gaze centre dysfunction movements) – Bil. Pontine gaze centre dysfunction
6.6. Ocular Dip ( Slow Arrhythmic Downward And fast Upward eye Ocular Dip ( Slow Arrhythmic Downward And fast Upward eye movement with normal Dolls) – Diffuse cortical Axonal Damagemovement with normal Dolls) – Diffuse cortical Axonal Damage
7.7. Saccadic (Fast) movements in Coma – PsychologicalSaccadic (Fast) movements in Coma – Psychological
8.8. Horizontal divergent eyes – DrowsinessHorizontal divergent eyes – Drowsiness
9.9. Bilateral Abducted eyes – 3Bilateral Abducted eyes – 3rdrd N Dysfunction N Dysfunction
10.10. Bilateral Adducted eyes – 6Bilateral Adducted eyes – 6thth N Dysfunction (ICP) N Dysfunction (ICP)
NEU.EXAM- 9.Ocular Movements.NEU.EXAM- 9.Ocular Movements.
(B)OCULOCEPHALIC (DOLLS) REFLEX :(B)OCULOCEPHALIC (DOLLS) REFLEX :
Turn the head briskly side to side – Conjugate Turn the head briskly side to side – Conjugate
opposite eye movements are normal (Could opposite eye movements are normal (Could
not be elicited in normal persons due to not be elicited in normal persons due to
supranuclear control)supranuclear control)
Normal reflex in coma indicates Normal reflex in coma indicates
bihemispherical / metabolic abnormality bihemispherical / metabolic abnormality
Absent dolls due to (upper) brainstem lesionAbsent dolls due to (upper) brainstem lesion
NEU.EXAM- 9.Ocular Movements.NEU.EXAM- 9.Ocular Movements.
(C) OCULOVESTIBULAR (CALORIC) REFLEX :(C) OCULOVESTIBULAR (CALORIC) REFLEX :
Flex the Head 30Flex the Head 30° -- Lavage the ear with cold ° -- Lavage the ear with cold
((3030°C) water -30 ml – Observe for 30 sec – Opp. °C) water -30 ml – Observe for 30 sec – Opp.
Side Nystagmus is normal response (COWS) – Side Nystagmus is normal response (COWS) –
Tonic Eye deviation to same sideTonic Eye deviation to same side
No Nystagmus but normal tonic phase – No Nystagmus but normal tonic phase –
Bihemispherical Bihemispherical
Absent Response – Deep Coma / BS dysfunctionAbsent Response – Deep Coma / BS dysfunction
Asymmetric Response – BS lesionAsymmetric Response – BS lesion
Conjugate gaze paresis -- Hemispherical / Pontine Conjugate gaze paresis -- Hemispherical / Pontine
NEU.EXAM- 9.Ocular Movements.NEU.EXAM- 9.Ocular Movements.
NEU.EXAM–MOTOR RESPONSESNEU.EXAM–MOTOR RESPONSES
Best indicator for the severity of comaBest indicator for the severity of coma
Observe Spontaneous movements for symmetry Observe Spontaneous movements for symmetry
and purposeand purpose
Check tone for symmetry / Bil LL Check tone for symmetry / Bil LL ↑ tone favors ↑ tone favors
Herniation.Herniation.
Induce increasing stimuli & observe symmetryInduce increasing stimuli & observe symmetry
1. Verbal command -(open eyes, Show 2 fingers)1. Verbal command -(open eyes, Show 2 fingers)
2.Sternal rub / pressure- (Purposeful / Gross 2.Sternal rub / pressure- (Purposeful / Gross
localizing responses)localizing responses)
3.Nailbed Pressure :3.Nailbed Pressure :
a) Withdrawl – Motor cortexa) Withdrawl – Motor cortex
b) Decortication (Flexion of the Elbow & wrist with b) Decortication (Flexion of the Elbow & wrist with
supination of the arm)– Deep Hemisphere / Upper supination of the arm)– Deep Hemisphere / Upper
midbrain level inv of pyramidal tract midbrain level inv of pyramidal tract
c) Decerebration (Extension of Elbows Wrist & c) Decerebration (Extension of Elbows Wrist &
Pronation) – Pons / Upper medullary lesionPronation) – Pons / Upper medullary lesion
NEU.EXAM–MOTOR RESPONSESNEU.EXAM–MOTOR RESPONSES
DIAGNOSTIC TESTINGDIAGNOSTIC TESTING1. Head CT (or MRI) Scan :1. Head CT (or MRI) Scan :
Great boon for the Diagnosis of structural lesions.Great boon for the Diagnosis of structural lesions.
Mostly CT is enough & is Quick for the Patient & Doctor.Mostly CT is enough & is Quick for the Patient & Doctor.
All types of ICH, Tumor & Hydrocephalus.All types of ICH, Tumor & Hydrocephalus.
Bihemispherical Infarcts, BS lesion, DAI, Meningitis, Encephalitis, Bihemispherical Infarcts, BS lesion, DAI, Meningitis, Encephalitis,
isodense SDH & CVT may be missed by CT Scan.isodense SDH & CVT may be missed by CT Scan.
Contrast when required / Bone window - TraumaContrast when required / Bone window - Trauma
2. Lumbar Puncture :2. Lumbar Puncture :
Exclude ICT / Mass effect by CT Scan Before LPExclude ICT / Mass effect by CT Scan Before LP
To Diagnose Meningitis /Encephalitis / SAHTo Diagnose Meningitis /Encephalitis / SAH
Do not postpone Treatment for Men’s if LP is delayedDo not postpone Treatment for Men’s if LP is delayed
3. EEG:3. EEG:
1. Progressively increasing background slowing
corresponds to the level of consciousness.
2. Triphasic waves in hepatic (other) Encephalopathies.
3. Asymmetric slowing in hemispherical lesion.
4. Alpha coma : Alpha waves all over – pontine / Diff.Cort
5. Excessive Beta waves in Sedative Intoxication.
6. Electrical Status in Non-Convulsive SE.
7. Normal Alpha Activity seen in Locked in syndrome &
Hysteria.
DIAGNOSTIC TESTINGDIAGNOSTIC TESTING
EMERGENCY TREATMENT FOR COMAEMERGENCY TREATMENT FOR COMA
1. ICSOL: Surgical intervention1. ICSOL: Surgical intervention
2. INCREASED ICP (For buying time):2. INCREASED ICP (For buying time):
a. Head Elevationa. Head Elevation
b. Intubation / Hyperventilationb. Intubation / Hyperventilation
c. Sedation if Agitated (midazolam) c. Sedation if Agitated (midazolam)
d. 20% Mannitol 1gm/kg d. 20% Mannitol 1gm/kg
e. Dexamethasone 10mg IV Q6H e. Dexamethasone 10mg IV Q6H
3. ENCEPHALITIS (HSE): 3. ENCEPHALITIS (HSE): Acyclovir 10mg/kg IV Q8HAcyclovir 10mg/kg IV Q8H
4. MENINGITIS : Ceftriaxone +Ampicillin4. MENINGITIS : Ceftriaxone +Ampicillin
CAUSES OF STUPOR AND COMACAUSES OF STUPOR AND COMA1. STRUCTURAL1. STRUCTURAL a)Traumaa)Trauma
i.ICHi.ICH
ii.Diff Axon Injuryii.Diff Axon Injury
iii.Concussioniii.Concussion
b)CVAb)CVA
i.ICH / SAHi.ICH / SAH
ii.Hemisp / BS Infii.Hemisp / BS Inf
iii.CVTiii.CVT
iv.HTN’ve Encep’thyiv.HTN’ve Encep’thy
c)Infectionc)Infection
i.Meningitisi.Meningitis
ii.Encephalitisii.Encephalitis
iii.Abscessiii.Abscess
d)Inflammatoryd)Inflammatory
i.Autoimmune Vasculitisi.Autoimmune Vasculitis
ii.Demyelinationii.Demyelination
e)Neoplasme)Neoplasm
f)Hydrocephalus f)Hydrocephalus
2. TOXIC / METABOLIC2. TOXIC / METABOLIC a)Global Hypoxia / Ischemiaa)Global Hypoxia / Ischemia
b)Elec’te / Acid-Base Disordersb)Elec’te / Acid-Base Disorders i.pH Disturbancesi.pH Disturbances ii. Hyper/Hypo Natremiaii. Hyper/Hypo Natremia iii. Hyper/Hypo Glycemiaiii. Hyper/Hypo Glycemia iv. Hyper/Hypo Calcemiaiv. Hyper/Hypo Calcemia c)Drug intoxic’n / Withdrawlc)Drug intoxic’n / Withdrawl d)Temp’re (Hyper/Hypo thermia)d)Temp’re (Hyper/Hypo thermia) e)Organ System Dysfunctione)Organ System Dysfunction i.Liveri.Liver ii.Kidneyii.Kidney iii.Thyroidiii.Thyroid iv.Adrenaliv.Adrenal v.Cardiac /Respiratoryv.Cardiac /Respiratory f)Seizures and Post-ictal states f)Seizures and Post-ictal states g)Thiamine / B12 Deficiencyg)Thiamine / B12 Deficiency
3. PSYCOGENIC COMA3. PSYCOGENIC COMA
CEREBRO VASCULAR ACCIDENTCEREBRO VASCULAR ACCIDENT
10% of coma are due to CVA10% of coma are due to CVA
Variable depth of coma with HemiplegiaVariable depth of coma with Hemiplegia
Large infarct / ICH -Facial / Limb WeaknessLarge infarct / ICH -Facial / Limb Weakness
IVH -Decerebration / MeningismusIVH -Decerebration / Meningismus
Brain Stem Infarct - BS SignsBrain Stem Infarct - BS Signs
VBI - Loss of Bl.Supply to RAS - Drop attackVBI - Loss of Bl.Supply to RAS - Drop attack
SAH - Th’rclap HA , Mening’s , Focal deficitsSAH - Th’rclap HA , Mening’s , Focal deficits
HT.E - Blindness,Fits,Paps,Retino/Nephro’yHT.E - Blindness,Fits,Paps,Retino/Nephro’y
CVT-Fits,HA,ICT,Mening’s,Focal DeficitsCVT-Fits,HA,ICT,Mening’s,Focal Deficits
Small vessel occl’n-SLE,SBE,DIC,TTPSmall vessel occl’n-SLE,SBE,DIC,TTP
Ischemic Gliosis of PonsIschemic Gliosis of Pons
SLESLE
Pontine InfarctPontine Infarct
Intra Cerebral HemorrhageIntra Cerebral Hemorrhage
ANEURYSM & SAHANEURYSM & SAH
10 / 1,00,000 PER YEAR10 / 1,00,000 PER YEAR Frequently in femalesFrequently in females Age, HTN, Smoking, Alcohol –riskAge, HTN, Smoking, Alcohol –risk 70% gets Warning leaks70% gets Warning leaks 45% Manifest as COMA at the onset45% Manifest as COMA at the onset Suspicion, CT & LP are Diagnostic methodsSuspicion, CT & LP are Diagnostic methods MRA, CT Angio & DSA for confirmationMRA, CT Angio & DSA for confirmation Close monitor’g, rest, sedate, Vol.expaners, AED, Close monitor’g, rest, sedate, Vol.expaners, AED, Avoid Vasospasm, Anti HTN, & DulcolaxAvoid Vasospasm, Anti HTN, & Dulcolax Plan Surgery at the earliest Plan Surgery at the earliest
AneurysmsAneurysms
13% of coma are due to trauma13% of coma are due to trauma
History & Evidences of external InjuryHistory & Evidences of external Injury
Concussion – Immediate / Late ComaConcussion – Immediate / Late Coma
Contusion / Laceration – Foc.def / Seiz’sContusion / Laceration – Foc.def / Seiz’s
EDH (MMA H’ge) - Lucid Interval EDH (MMA H’ge) - Lucid Interval
SDH – Delayed SymptomsSDH – Delayed Symptoms
Monitor T,P,BP,ICP,CT, MRI,C.Spine for Monitor T,P,BP,ICP,CT, MRI,C.Spine for all Trauma.all Trauma.
TRAUMATRAUMA
Contusion / Concussion / DAI / SAHContusion / Concussion / DAI / SAH
Common Cause of ComaCommon Cause of Coma
Flushed face, Conj.inj., Bounding pulse, Dil’d pp,Flushed face, Conj.inj., Bounding pulse, Dil’d pp,
Alcohol from Breath, Stomach & BloodAlcohol from Breath, Stomach & Blood
ICH, Trauma, SDH, Wernicke’s Encp’thyICH, Trauma, SDH, Wernicke’s Encp’thy
Urgent CT, LFT, Coag’ln profileUrgent CT, LFT, Coag’ln profile
Inj.B1 & 50% Dextrose if hypoglycemicInj.B1 & 50% Dextrose if hypoglycemic
AED if H/O seizuresAED if H/O seizures
ALCOHOL INTOXICATIONALCOHOL INTOXICATION
Tongue bite, Froath, Bloody sputum, InjuryTongue bite, Froath, Bloody sputum, Injury
Etiology of convulsion may be differentEtiology of convulsion may be different
Confusion & IrritabilityConfusion & Irritability
Brief stupor and profound sleepBrief stupor and profound sleep
To rule out Non-Convulsive Status To rule out Non-Convulsive Status
Post ictal statePost ictal state
DIABETESDIABETES
Hypo is worse so give IV dextrose Hypo is worse so give IV dextrose
Dec DTR, T, BP, Hyd’n, / Inc P, RDec DTR, T, BP, Hyd’n, / Inc P, R
Smell of AcetoneSmell of Acetone
Suicidal/ Homicidal/ AccidentalSuicidal/ Homicidal/ AccidentalDrugs and ToxinsDrugs and ToxinsHistory / Physical findingsHistory / Physical findingsLavage/ Symptomatic/ Antidote/ Tt ComplLavage/ Symptomatic/ Antidote/ Tt ComplNo Lateralizing signsNo Lateralizing signsDepth of coma Acc to Strength & AmountDepth of coma Acc to Strength & Amount
PoisoningPoisoning
MeningitisMeningitisHA, Fever, LOC, Meningismus (not in age HA, Fever, LOC, Meningismus (not in age extremes & Imm. supp), ICPextremes & Imm. supp), ICPENT infection, SBE,ENT infection, SBE,Rash in mening.meng’sRash in mening.meng’sDo CT before LPDo CT before LP
ENCEPHALITISENCEPHALITIS
Present with Fever, Meningismus, Altered Present with Fever, Meningismus, Altered sensorium, seizures and focal Deficits.sensorium, seizures and focal Deficits.Usually the Seizures are difficult to controlUsually the Seizures are difficult to controlEEG& CSF are better diagnostic tools than ImagingEEG& CSF are better diagnostic tools than ImagingHSEHSE affects FT regions asymmetrically present affects FT regions asymmetrically present with focal seizureswith focal seizuresEEG may show PLEDs, Focal epileptic activity or EEG may show PLEDs, Focal epileptic activity or slowingslowingMRI shows signal alterations in inferior FT regions MRI shows signal alterations in inferior FT regions asymmetricallyasymmetricallyIV Acyclovir is the Treatment of choice with full IV Acyclovir is the Treatment of choice with full dose AEDdose AED
Herpes Simplex EncephalitisHerpes Simplex Encephalitis
PSEUDOCOMAPSEUDOCOMA1. PSYCHOGENIC COMA1. PSYCHOGENIC COMA
Negativistic Behavior (Resists opening eye)Negativistic Behavior (Resists opening eye)Avoidance Behavior (Hand avoids face on dropping)Avoidance Behavior (Hand avoids face on dropping)Intact Saccades / Normal Caloric responseIntact Saccades / Normal Caloric responseRecovery on very painful stimuliRecovery on very painful stimuli
2. LOCKED IN SYNDROME2. LOCKED IN SYNDROMEComplete paralysis except for vertical eye movementsComplete paralysis except for vertical eye movementsPt usually alert and can communicate thru’ EOMPt usually alert and can communicate thru’ EOMDue to bilateral Pontine Damage (Infarct)Due to bilateral Pontine Damage (Infarct)
3. AKINETIC MUTISM 3. AKINETIC MUTISM (Motionless, Mindless Wakefulness)Extreme psychomotor retardation- Appears awakeExtreme psychomotor retardation- Appears awakeShow Delayed Limited responsesShow Delayed Limited responsesDue to Extensive Thalamic / Frontal DamageDue to Extensive Thalamic / Frontal Damage
VEGETATIVE STATEVEGETATIVE STATELoss of Awareness of self and surroundings.Loss of Awareness of self and surroundings.Normal sleep wake cycles & BS reflexes.Normal sleep wake cycles & BS reflexes.Normal metabolic and circulatory functions.Normal metabolic and circulatory functions.Normal eye opening / closure & Swallowing.Normal eye opening / closure & Swallowing.Eye movements & Sensory Localization – Poor.Eye movements & Sensory Localization – Poor.Doesn’t obey requ’s / No comprehensible words.Doesn’t obey requ’s / No comprehensible words.Preserved Hypothalamic & Autonomic fns.Preserved Hypothalamic & Autonomic fns.Above findings lasting > 1 month – PVS.Above findings lasting > 1 month – PVS.CVA, SAH, Trauma, Toxin, Injury, Infn, Arrest etc.,CVA, SAH, Trauma, Toxin, Injury, Infn, Arrest etc.,Low amplitude irregular Delta in EEG.Low amplitude irregular Delta in EEG.Cortical necrosis, multi-infarcts, Diffuse neuronal Cortical necrosis, multi-infarcts, Diffuse neuronal loss and gliosis of neocortex, hippocampus loss and gliosis of neocortex, hippocampus thalamus & purkinje cells – BS relatively intact.thalamus & purkinje cells – BS relatively intact.
GENERAL CARE FOR COMATOSE PTSGENERAL CARE FOR COMATOSE PTS
1.1. Protect airway / Adeq. Vent’n & O2 / NPO Protect airway / Adeq. Vent’n & O2 / NPO
2.2. Good Hydration – Prefer isotonic SalineGood Hydration – Prefer isotonic Saline
3.3. Nasogatric adeq. calorie feed with smaller tube Nasogatric adeq. calorie feed with smaller tube
4.4. Prevent Bedsore – Q2H Position / Water bedPrevent Bedsore – Q2H Position / Water bed
5.5. Protect Eyes by keeping closed / LubricantsProtect Eyes by keeping closed / Lubricants
6.6. Ranitin to prevent Stress ulcer / Stool softenerRanitin to prevent Stress ulcer / Stool softener
7.7. Aseptic Catherization / Intermittent catheteris’nAseptic Catherization / Intermittent catheteris’n
8.8. Passive Limb Exercises to prevent ContracturesPassive Limb Exercises to prevent Contractures
9.9. Calf exe / Stocking / Heparin to avoid DVTCalf exe / Stocking / Heparin to avoid DVT
BRAIN DEATHBRAIN DEATH
State of cessation of cerebral activity with State of cessation of cerebral activity with normal Heart function, Respiration being normal Heart function, Respiration being maintained by Ventilators.maintained by Ventilators.
Brain death is the Death of the IndividualBrain death is the Death of the Individual
Three Essential elements for DxThree Essential elements for Dx 1. Widespread Cortical Destruction (Unresponsive to all stimuli)1. Widespread Cortical Destruction (Unresponsive to all stimuli)
2.Global BS Damage (Loss of all BS reflexes)2.Global BS Damage (Loss of all BS reflexes)
3.Lower BS destruction – Complete Apnea3.Lower BS destruction – Complete Apnea
Exclude Drug induced / Hypothermic CNS Exclude Drug induced / Hypothermic CNS DepressionDepression
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