Coma
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Transcript of Coma
ALTERED MENTAL STATUS & COMA
Dr makeldin
DESCRIPTIONS
• Unarousable unresponsiveness• Light Coma• Deep Coma• Loss of either arousal or cognititon• Stupor• Obtundation• Clouding of consciousness
GLASGOW COMA SCALE E : Eye OpeningV : Best Verbal ResponseM : Best Motor Response
total scoring
-> Open
* Spontaneously 4
* To Verbal 3
* To Pain 2
-> No response 1
EYE OPENING
BEST VERBAL RESPONSE
- Oriented & converses 5
- Disoriented & converses 4
- Verbalizes 3
- Vocalizes 2
- No response 1
BEST MOTOR RESPONSE-> To Verbal Command
* Obey 6
-> To Painful Response
* Localizes pain 5
* Flexion withdrawal 4
* Flexion - abnormal 3
* Extension – abnormal 2
* No response 1
* Greek word “ Koma ” meaning state of sleep” * Hippocrates, describe this very state of the brain at the lowest end of the spectrum of function. * "coma is a state of unresponsiveness from which an individual has not yet been aroused ".
What is COMA
Glasgow Coma Scale Score of 8 or less
COMA
Advanced Trauma Life Support (ATLS)
Level of consciousness-- AVPU
A – AlertV – Response to Verbal stimuliP – Response to Pain stimuliU - Unconscious
Altered Mental Status ?
What are the causes of
Emergency Medicine Mnemonic in Altered Mental Status
A E I O U T I P S
A – AlcoholE – Endocrine / ElectrolytesI – InsulinO - Opiate / OxygenU - Uremia
A E I O U ?
T I P S ?
T – Toxin / trauma / temperatureI – InfectionsP – Psych / PorphyriaS – SAH, stroke, shock, space occupying lesion
Usually stuporousBlood alcohol > 200mg/dl
A - ALCOHOL
Blood EtOH level 20-50 Impair fine motor function
50-100 Impair judge & coordination
100-150 Difficult walk & balance
150-200 Lethargy
300 Coma
400 Respiratory depression
500 Potential death
E – ENDOCRINE / ELECTROLYTES*Hypothyroidism*Hyperthyroidism*Hyperparathyroidism*Adrenal hypofunction *Diabetes Mellitus*Hyponatremia <120mEq/dl*Hepatic coma *Serum Osmolality <260mOsm/L > 330mOsm/L*Hypercalcemia Ca >19mg/dl*Hyperviscosity > 4cp (1.4-1.8)
I – INSULIN
HypoglycemiaAdult Plasma < 45mg/dlChild < 40mg/dl
HyperglycemiaGlucose > 600 + OSM > 340
O – OPIATES / OXYGEN
* Meperidine,opiate,codeine, morphine,cocaine etc
* CO2 retension + acidosis Hypoxia
U – UREMIA
BUN sudden increase > 60mg/100ml
T- Toxin /Trauma/Temperature
Toxin –- Hypnotic agent, barbiturateTrauma –- multi-factorialTemperature –- *Hyperthermia > 40.5 c
*Hypothermia < 32 c
I : INFECTIONS
CNS & Systemic Infection
P : Psych / Porphyria
Psychogenic unresponsiveness
Porphyrias Anomalies in pigment metabolism Classified into 8 types Symptoms : abdominal pain, diarrhea, constipate,dysuria,ileus,muscle hypotonia, resp insufficiency,sensory neuropathy, seizure, photosensitivity,skin lesion.
S
SAH: sudden onset severe headache.Space occupying lesion:
tumour/blood /abscess/infarction Stroke:hemorhage/infarction/thromboticShock: hypovolemic/obstructive, cardiogenic/vasogenic/anaphylatic pharmacologic/neurogenic
CLINICAL PRESENTATION ?
Hypothermia
- Infection, hypoglycemia, myxedema coma, alcohol & sedative overdose.
Fever
- Infection, thyrotoxicosis, sympathomimetic, hypothalamic, hemorrhage, anticholinergics, neuroleptic malignant syndrome.
Hypertension
- structural lesion, HTN encephalopathyHypotension- systemic disease, sepsis
HEENT
Mydriasis- organophosphateMiosis- narcotic, anticholinergic, potine lesionLoss of pupillary reflex or anisocoria- structural lesionEvidence of head trauma- contusion, hematoma, laceration, hemotympanum.Neck- nuchal rigidity, meningitis, SAH
NEUROLOGICAL
Decorticate Posturing- suggest severe damage above the midbrain.
Decerebrate Posturing- suggest damage at the midbrain or diencephalon
Asymmetrical Movements- structural lesion
Persistent twitching of an extremity- stutus epilepticus
Treatment in ER
Initial Stabilization A - Airway B – Breathing C – Circulation
E D TREATMENT
B A N G
B : B1 Vitamin
A : Anexate
N : Naloxone
G : Glucose
Wernicke’s Encephalopathy
Confusion, apathy, drosiness, ataxic, nystagmus, ophthalmoplegia.
Cause : chronic alcohol abuse & thiamine deficiency
Tx : Thiamine IV Alinamine F, Nutrase
Flumazenil ( Anexate )
0.2 mg IV over 15 sec.
Also effective in Hepatic coma
Naloxone ( Narcan )
0.4-2mg IV Q2-3min
Long acting :
•Nalmefene
•Naltrexone
Hypoglycemia
* Give 20-50g of 50% Glucose. * Then constant IVF glucose till pt can take by mouth.
THE END