Mayo Clinic Flagler COMA Stroke Education Day May 3...
Transcript of Mayo Clinic Flagler COMA Stroke Education Day May 3...
W David Freeman, MD
Professor of Neurology and Neurosurgery
No conflicts of interest or disclosures
Mayo Clinic Flagler Stroke Education Day
May 3rd 2019
COMA
Approach to the Comatose Patient
Objectives • Perform a neurological
coma exam • Assess ABC’s • Differential Diagnosis of
coma • Management
Neurocrit Care. 2015 Dec;23 Suppl 2:S69-75. doi:
10.1007/s12028-015-0174-1.
Coma – What is it?
Arousal: wakefulness, eye opening
Awareness: able to follow commands, content processing
Checklist for the 1st hour ☐ Evaluate/treat ABC’s and C-spine
☐ Rule out/treat hypoglycemia or opioid overdose
☐ Obtain Serum chemistries, ABG, urine toxicology screen
☐ Obtain emergent cranial CT to evaluate for structural stroke causes
☐ Determine if coma etiology is structural or non-structural
Approach to the Patient with Coma
Assess level of consciousness
IV access
Airway
Breathing
Circulation
C-spine immobilization
Approach to the Patient with Coma • Hypoglycemia
• Blood glucose < 70mg/dL (3.9mmol/L)
• 50ml of 50% dextrose
• Thiamine 100 mg IV before dextrose in patients at risk for nutritional deficiency
• Opioid Toxicity
• Naloxone 0.04-0.4mg IV repeated up to max dose of 4mg
Case Unresponsive Patient 75 year old male
Unresponsive to voice
Found in hotel room by housekeeping
Last known well last night (10pm)
Brought to the ED by EMS
Neurological Assessment 1) Level of responsiveness 2) Brainstem assessment 3) Evaluation of motor
responses, tone and reflexes 4) Appraisal of breathing
patterns Note any asymmetry in the examination
Level of Responsiveness (Coma scales)
• Eye opening
• Motor response
• Verbal response
Glascow Coma Scale (GCS)
• Eye opening
• Motor response
• Brainstem response
• Respiratory response
Full Outline of UnResponsiveness
Scale (FOUR)
Brainstem Assessment
• Pinpoint: raises concern of pontine damage
• Large, unreactive: midbrain damage, 3rd nerve compression
Pupillary Response
Corneal Reflex
Visual threat response
• Spontaneous
• Oculocephalic Reflex (Doll’s Eyes)
• Vestibulo-ocular Reflex (cold caloric testing)
Eye movements
Cough reflex
Gag reflex
Motor Function
Spontaneous movement or to noxious stimuli
Posturing in structural & metabolic coma
• Flexor (decorticate)
• Extensor (decerebrate)
Muscle tone
Reflexes
Distinguish between purposeful and reflex activity
Breathing
Breathing patterns may help localize
• Midbrain and Pons Neurogenic Hyperventilation
• Pons Cluster breathing
• Medulla Ataxic (Biot’s) breathing
Cheyne-Strokes- Cerebrum , OSA, CHF
Arch Neurol. 2006 Oct;63(10):1487-90.
Case Neurological Assessment
• Vitals: • Afebrile • HR 160 bpm • BP 105/70 mmHg • RR 12 /min • SpO2 100%
• GCS 3 (E1, V1, M1) • No evidence of trauma
Case Neurological Assessment
• Blood glucose normal
• Pupils are symmetric, reactive and enlarged to 8mm; eyes are dry
• Motor tone normal
• Myoclonic jerks are present
• He is intubated and ventilated for airway protection
• Bladder is distended (>1000cc urine)
• Wife is contacted over the phone Picture attributed to Nutschig at the English Language Wikipedia
Valuable clues to the etiology of coma
• Time course of unconsciousness • Abrupt • Gradual
• PMH, PSH • Meds, toxin exposures • Social history
Focused Presenting History and Past Medical History
Case
PMH MEDS
Coronary Artery Disease Aspirin
DM Type 2 Metformin
Depression Amitriptyline at night Desvenlafaxine daily
Recommended STAT Labs
LABS
☐ Bedside blood glucose, if not done
☐ Serum Chemistries
☐ Arterial blood gas
☐ CBC
☐ Toxicology studies: ☐ETOH ☐Urine toxicology screen
☐ Microbiology studies
☐ Consider co-oximetry
Initial Formulation
Causes of Coma
Neurologic Causes Toxic Metabolic Causes
Trauma (severe) Drug overdose
Neurovascular (stroke) Metabolic endocrine electrolyte hepatic, renal hypercapnea, hypoxia
CNS infection (encephalitis) Environmental toxins
Neoplasm (primary, metastasis)
Seizure/status epilepticus
Neuroinflammatory Autoimmune encephalitis, ADEM
Other: PRES, HIE
Back to the Case
Structural insult? (stroke/hemorrhage)
Hx CAD
rapid onset
abnormal pupils
motor exam & reflexes
Metabolic hx DM hx depression Medication overdose?
versus
Brain Imaging
Unclear cause or focal exam
• Noncontrast head CT STAT
• CT angiography (CTA) and CT perfusion (CTP)
• Concern for ischemic stroke
• CT with contrast
• Concern for CNS infection
Persistent Uncertainty
Additional testing
MRI
Lumbar puncture
Continuous EEG
Case Conclusion
• CT Head normal, EEG without seizures
• Labs show metabolic acidosis
• EKG shows widened QRS and prolonged QTc
• Tricyclic antidepressant toxicity suspected
• Treatment with sodium bicarbonate drip
• Within 36 hours, his EKG changes resolved and he woke up
• He admitted to overdosing his amitriptyline and desvenlafaxine
Handoff Checklist ☐ Clinical presentation
☐ Relevant past medical/surgical history
☐ Findings on neurological examination
☐ Relevant labs
☐ Brain imaging, LP, or EEG results if available
☐ Treatments administered so far
Questions?