Approach to the comatose patient
Stephen Lo
Introduction
Focus on developing a structured approach to comaCan be also applied to exam questions
Case50 year old polynesian lady presented with headache followed by
LOCHow would you assess and manage this patient?
Investigations
My approachInitial managementDifferential diagnosisInvestigationsManagement
Initial steps: safety + ensure adequate resources
Ask for resourcesABC, basic resuscitation
Assessment of airway, breathing, and circulation
Airway patencyAirway protection:
What is the GCS Is there protective reflexes presentWhat is the risk of aspirationAre there secretions
Rate and pattern of ventilation
Circulation: signs of shock, hypotension. Consider maintaining CPP.
In this case, I would put Blood sugar levels at the priority of the ABCs
Differential diagnosisNeed to construct a list of differential diagnosis at this point.
Approach to the diagnosisNeed a simple way of classifying causesIntracranialExtracranial
Intracranial Consider surgical sieve or other pneumonics Need to include the key ones such as: bleed, stroke, infection, trauma, Seizures, rarer causes such as tumours, autoimmune, vasculitis, PRES context specific differentials such as vasospasm, hydocephalus in SAH
Extracranial These are generally metabolic in nature. Again, have a sieve that you are familiar with, but need to include the
most common ones including:
Drugs: direct effect, indirect effects
Acid base
Hypoxia/hypercarbic
Temperature
Organ function: Kidney and liver
Nutritional
Electrolyte disturbance
Endocrine
Sepsis
Mimics of comaSevere peripheral neuropathy
Guillain Barre syndromeBotulismCritical illness neuropathy
Locked in syndromeAkinetic mutism
AssessmentHistory and examination to rule out or in your differentialsCatagorize into three broad categories based on patient’s signsComa with focal signs: Suggests an intracranial event
Coma with meningism: Suggests meningitis, SAH
Coma without signs: Suggests a very diffuse intracranial lesion or an extracranial cause
Investigations Consider all your options Systemic investigations CT head Lumbar puncture: MCS, PCR, antibodies CT angiogram EEG MRI SSEPs Cerebral angiogram
What’s your management now?Medical managementSpecific managementPosition of patient, CO2 control, BP control, Osmotherapy, sedation,
sugar, seizure control, temperatureGeneral managementInterventionsRadiological interventionsSurgical management
Case 249 yo male thai chef that was found collapsed at home, brought
in by ambulance.How would you manage this patient?
AssessmentABC: Noisy breathingGCS:
E1V2M5Sats: 84 % on 6LBP 190/80, HR 90/min
Further clinical assessmentRight side movement less than leftPupils equal and reactive
Investigations
Finding underlying causesThromboembolic
Consider source of clotBleeding
Is there an underlying abnormalityInfection
Are there underlying structural abnormality or immunosuppressionEpilepsy
Adult onset always need to consider cause
Further investigationsASD on echoParadoxical embolus and therefore infarct
Other learning pointsThat an extensive unilateral lesion can also cause reduced LOC
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