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Approach to coma in emergency department
This document provides an overview of the approach to evaluating and managing a patient presenting with coma in the emergency department. It begins by defining coma and outlining the pathophysiology involving impaired arousal from damage to the brainstem arousal system or cerebral cortex. The primary and secondary surveys are described which involve assessing the airway, breathing, circulation, disability and exposure. Differential diagnosis, common etiologies, ancillary testing, imaging and disposition are discussed. The key steps in the emergency department include stabilizing the airway and breathing, obtaining vital signs, blood glucose, brief history, full examination, imaging of the head and further testing and treatment based on diagnosis.
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Approach to coma in emergency department
- 1. Approach to comain ED Runal Shah PGY1 MEM, KDAH
- 2. Case Scenario 43/Malebrought to ED by Cardiac ambulance at 11.00 am c/o unresponsiveness x 7.00 am A – Snoring sounds, B – breathing equal chest rise, RR 10/min C – cold periphery, BP- 170/90, P-110/min D – GCS E1,V2,M2 – Pupils 1.5mm sluggish How will you evaluate ??
- 3. Definition COMA –Deep sleep like state from which the patient cannot be aroused. o Vegetative state o Catatonia o Akinetic mutism o Locked in state
- 4. Pathophysiology Consciousness –Awareness of the self or surroundings Cognition – Orientation + Judgment Arousal – Level of Consciousness (Fully aroused to Comatose) ARAS – Anatomically located in Paramedian tegmental zone of dorsal midbrain – responsible for arousal and cortical activation Cerebral cortex – contains Cognition centers – determine content of consciousness Insult to cerebral cortex or brainstem can independently cause Coma; vulnerable to Metabolic derangements, Toxins, Mechanical Injury. If ARAS is impaired, cerebral cortex cannot be aroused.
- 6. Differential Diagnosis Neurologic Infectious Metabolic Toxic Pulmonary, hypoxia Cardiovascular
- 9. Etiology Structural Trauma – SDH –EDH – Cerebral Concussion- Contusion Stroke Syndromes – Embolism – Thrombosis – Hemorrhagic Tumors Infections Age related Infant – Infection – Trauma/ Abuse – Metabolic Child – Toxic ingestion Adolescent/ Young Adults – Toxic – Recreational Drug – Trauma Elderly – Meds/ OTC drugs – Infection – Stroke
- 10. Approach in ED Primary Survey – Airway – Breathing – Circulation – Disability (GCS, Pupils, NIHSS) – Exposure Vitals Blood glucose Brief History of events (SAMPLE) Secondary Survey (Head to toe)
- 11. Primary Survey Airway: Patent / Compromised ? Intervene for Hypoxia / Obstruction / Dyspnea Proper position / Head tilt- Chin lift / Jaw thrust Oxygen Supplementation Nasal Prongs, Face mask, Venturi mask, Non- rebreathing mask, Bag-Mask, ET intubation OPA, NPAs
- 12. Primary Survey Breathing: Equal chest rise? Use of accessory muscle Air entry bilateral equal? Adventitious sounds – Crepts/ Rhonchi/ Stridor ?
- 13. Primary Survey Circulation: Peripheries Cold/ Warm, Capillary Refill Time Blood pressure Pulse : Rate, Rhythm, Volume Intravenous Access – Blood collection & Sugars IV fluids according to Blood sugars
- 14. Primary Survey Disability: GCS (E V M) Pupils – Size, Shape Reactivity to light Conjugate movements NIHSS scoring C-Spine immobilization in case of Trauma
- 15. History • Trauma • Cardiacarrest • Drug overdose/ ingestion • Neurological- – Circumstances & rapidity – Antecedent symptoms – Confusion, weakness, headache, fever, seizures, double vision, vomiting – Use of Meds, Drugs and Alcohol – Chronic liver, kidney, heart, other medical disease • Direct interrogation with Family members, bystanders, Ambulance staff/ paramedics
- 16. Brainstem Reflexes Pupillarysigns – Examine with bright diffuse light – Shape, size, reactivity – Anisocoria? Ocular movements – Spontaneous movements? – Conjugate deviation – Doll’s eye – Ocular bobbing/ dipping Respiratory pattern – Shallow slow regular breathing – Cheyne-Stokes – Kussmaul – Agonal gasp
- 17. Immediate Interventions IntravenousAccess Oxygen supplement Cardioscope monitoring Blood glucose ECG Emergent Head CT
- 18. Ancillary Testing BloodGlucose Arterial / Venous Blood gas Electrolytes Serum creatinine, BUN CBC Coagulation – PT, aPTT Thyroid profile Urine routine and Toxicology screening
- 19. Imaging Radiology CTBrain Plain CT Brain + Neck Angiography MRI Brain + MRAngiography Chest X-Ray Ultrasound _______________________________ ECG EEG
- 20.
- 21. Disposition Depending ondiagnosis, patient goes to Intensive care unit (ICU) /Operation room (OR) Hypoglycemia patient requires ED observation, and admission in ICU if Sugars are borderline or mentation doesn’t improve.
- 22. Thank You… Ref: Harrison's Principlesof Internal Medicine,19E Rosen's Emergency Medicine,8ed