Katrina Peariso MD PhD Prem A Kandiah MD Slides George A Lopez MD PhD ENLS Version 50 Approach to the Patient with Coma Editors Note Global Considerations The intent of the editors authors and reviewers of this ENLS topic was not to address all the variations in internation ID: 915552
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Slide2Content: Sara Stern-Nezer, MD, MPH; Katrina Peariso, MD, PhD;Prem A Kandiah, MDSlides: George A. Lopez, MD PhD
ENLS Version 5.0
Approach to the Patient with Coma
Slide3Editors’ Note: Global ConsiderationsThe intent of the editors, authors, and reviewers of this ENLS topic was not to address all the variations in international practice for the different diseases. We have discussed major practice variances (e.g., the availability of diagnostic testing, or the type of medications used) and encourage learners to use the ENLS algorithms as a framework on which any relevant local practice guidelines can be incorporated.
Slide4The Comatose PatientLearning ObjectivesPerform a neurological exam in a comatose patientAssess airway and need for assisted ventilationEstablish a diagnosis for the cause of comaTreat presumptively for the most likely cause of coma if indicated
Slide5What is coma?Arousal: wakefulness, eye opening Awareness: able to follow commands, content processing
Slide6Checklist for the 1st hour☐ Evaluate/treat circulation, airway, breathing and cervical-spine☐ Exclude/treat hypoglycemia or opioid/benzodiazepine overdose☐ Serum chemistries, ABG, urine/blood toxicology screen
☐
Emergent cranial CT (and CT-
angio
brain if appropriate) to determine if coma etiology is structural or vascular in etiology
Slide7Approach to the Patient with ComaAssess level of consciousnessAirwayBreathing CirculationCervical-spine immobilizationIV/IO access
Slide8Prehospital Checklist and HandoffAirway, breathing, ventilation issues GCS, pupils, and vital signs on presentationIV or IO access, site and patency (IV)Ruled out hypoglycemiaHistory from bystanders, witnesses, contextual or environmental observations (pill bottles, signs of trauma or seizure activity) Medications administered, dose and response (naloxone, dextrose etc.) Time when patient was last seen normal Prodromal symptoms when last seen
Slide9Prehospital pharmacological therapiesHypoglycemiaDextrose 50% 25-50 ml IVPeds: 25% 2-4 ml/kgOpioid overdoseNaloxone 0.04-.0.4 mg IV/IM Anticholinergic toxicityPhysostigmine 0.5-2 mg slow IV push
Slide10Approach to the Patient with ComaLevel of responsivenessAssess for brainstem reflexesEvaluation of motor responses, tone and reflexesNote any asymmetry in the examAppraisal of breathing patterns
Slide11Level of ResponsivenessGlasgow Coma Scale (GCS)Eye response (1-4 points)Verbal response (1-5 points)Motor response (1-6 points)Full Outline of UnResponsiveness Scale (FOUR)Eye openingMotor responseBrainstem responseRespiratory response
Slide12Pediatric GCSBased on age group< 1 year or > 1 year for Eye opening and Motor response0-23 month, or 2-5 years or > 5 years for Verbal responses
Slide13Level of ResponsivenessFull Outline of UnResponsiveness Scale (FOUR)Eye openingMotor responseBrainstem responseRespiratory response
Slide14Slide15Brainstem AssessmentPupillary responsePinpoint: raises concern of pontine damageLarge, unreactive: midbrain damage, 3rd nerve compressionUnilateral or bilateral?Corneal reflexVisual threat responseEye movementsSpontaneous or gaze preferenceOculocephalic Reflex (Doll’s Eyes)Vestibulo-ocular Reflex (caloric testing)Cough reflex, gag reflex
Slide16Pupillary ResponsesPupillary changePossible etiologies/localization
Pinpoint pupil
Opioids
Cholinergic intoxication
Pontine damage (interrupts descending sympathetic pathways)
Dilated, non-reactive pupils
Cerebral anoxia, global
Barbiturates
Atropine
Hypothermia
Brain death
Dilated, reactive pupils
Pretectal lesions
Stimulants (cocaine, methamphetamine), hallucinogens including PCP/LSD
Anisocoria (pupillary asymmetry)
3
rd
nerve compression from
uncal
herniation
Localized drug effect (e.g. ipratropium, tropicamide)
Mid-position, fixed or irregular
Midbrain lesion
Slide17Motor FunctionSpontaneous movement or to noxious stimuliPosturing in structural & metabolic comaFlexor (decorticate)Extensor (decerebrate)Muscle toneReflexesDistinguish between purposeful and reflex activity
Slide18Breathing PatternBreathing patterns may help localizeNeurogenic hyperventilationMidbrain and ponsCluster breathing/ataxic breathingPontomedullary junctionApneusisBilateral pontineCheyne-StokesGlobal/Metabolic encephalopathy
Slide19Respiratory patternPatternLocalization
Cheyne-Stokes
Global/metabolic encephalopathy
Impaired forebrain or diencephalon
Central neurogenic hyperventilation
Metabolic encephalopathy
High brainstem tumors (rare)
Apneusis
Bilateral pontine lesions
Cluster breathing/ataxic breathing
Pontomedullary junction lesions
Apnea
Lesions affecting ventrolateral medulla bilaterally (ventral respiratory group)
Slide20Approach to the Patient with ComaD50 (Dextrose 50%) IV if glucose < 70 mg/dLThiamine 100 mg IV before dextrose, in at risk patientsAdminister naloxone if opiate overdose is concernIV, IM, IO, Sub-Q, ETT, Nasal
Slide21Approach to the Patient with ComaHead CT to assess for structural etiologiesConsider CTA for possible vascular cause Basilar thrombosis
Slide22Approach to the Patient with ComaHistorical accountComorbiditiesMedicationsExposures
Slide23Valuable clues to the etiology of coma:Time course of unconsciousnessAbruptGradualPast medical history, past surgical historySocial history Focused Presenting History and Past Medical History
Slide24Case: Unresponsive Patient60-year-old maleUnresponsive to voiceFound in hotel room by housekeeperLast known well night beforeBrought to the ED by EMS
Slide25Vitals: Hypothermic, T 34ºCHR 60 bpmBP 185/95 mmHgRR 10 /minSpO2 92% on room airGCS 3 (E1, V1, M1)
Case: Unresponsive Patient
Slide26Case : Unresponsive Patient What is the best next step?Treat the elevated BP with nicardipine dripAssess ABCsSTAT head CTApply warming blankets to treat hypothermia
Slide27Case : Unresponsive Patient What is the best next step?Treat the elevated BP with nicardipine dripAssess ABCsSTAT head CTApply warming blankets to treat hypothermia
Slide28Case: Neurological AssessmentEyes closed, gaze disconjugate, OCR presentPupils are symmetric, reactive and enlargedNo response to pain, motor tone diminished, no DTRsWife is contacted over the phone
Slide29Case ABCs assessedPatient was intubated due to concern for unknown cervical spine stability and possible elevated ICPLabs sent
Slide30CasePMHMEDSCoronary Artery Disease
DVT
Aspirin
Apixaban
DM Type 2
Metformin
Depression
Amitriptyline
at night
Desvenlafaxine daily
Pharmacy contacted for possible emergent need of PCC as patient
on apixaban
Slide31Recommended STAT LabsLABS☐ Bedside blood glucose, if not done☐ Serum chemistries
☐ Arterial blood gas
☐ CBC
☐ Toxicology studies:
☐ETOH
☐
U
rine toxicology screen
☐ Microbiology studies
☐ Consider
co-oximetry
Slide32Initial Formulation
Slide33Neurologic CausesToxic Metabolic CausesTrauma (severe)Drug overdose
Neurovascular (stroke)
Metabolic
endocrine
electrolyte
hepatic, renal
hypercapnia, hypoxia
CNS infection (encephalitis)
Environmental
toxins
Neoplasm (primary,
metastasis)
Seizure/status
epilepticus
Neuroinflammatory
Autoimmune
encephalitis, ADEM
Other: PRES, HIE
Causes of Coma
Slide34Back to the Case
Structural insult? (Stroke/hemorrhage)
Hx CAD
Rapid onset
Abnormal pupils
Motor exam & reflexes
Metabolic
Hx DM
Hx depression
Medication overdose?
Opioids
versus
Slide35Case What is the best next step?Brain MRINaloxone 0.4 mg IV, then head CTHyperventilate patientHead CT
Slide36Case What is the best next step?Brain MRINaloxone 0.4 mg IV, then head CTHyperventilate patientHead CT
Slide37Brain ImagingUnclear cause or focal examNon-contrast head CT STATCT angiography (CTA) and CT perfusion (CTP)Concern for ischemic stroke CT with contrastConcern for CNS infection
Slide38Slide39Case ConclusionCT head with diffuse intraventricular hemorrhage, subarachnoid hemorrhage and hydrocephalusPharmacy notified for the urgent need and dosing of PCCNeurosurgery consulted for emergent EVDPatient hyperventilated until EVD placedMannitol infused (1 gram/kg IV)
Slide40Persisting Uncertainty?Additional testingMRILumbar PunctureContinuous EEG
Slide41Pediatric ConsiderationsABCs as in adultsChildren < 5 yrs – use the modified GCSTBI and infections are leading causes of comaSeptic shock is a common presentation of meningitis in childrenOther causes: hypoglycemia, diabetes (HHC), hypothermia, acid-base and electrolyte imbalances, seizures, intoxicationsSTAT neuroimaging if exam is focal or if unclear etiology
Slide42Clinical PearlsKey findings on the neurological examination of comatose patients can identify changes to suggest toxic syndromes that can lead to the rapid treatment of coma.Suspect basilar artery thrombosis in a comatose patient where the degree of coma is out of proportion to imaging findings or metabolic derangements/intoxication; early identification and revascularization are key in order to improve outcome.Elevated ICP can be seen in a variety of processes and cannot be excluded by imaging alone.
Slide43Communication☐ Clinical presentation☐ Relevant past medical/surgical history☐ Findings on neurological examination
☐ Relevant labs
☐ Brain imaging results. LP, or EEG if completed
☐ Treatments administered to date
Slide44Questions?