AMS and Coma

Question 1

Causes of AMS and Coma?

Answer 1

TIPS and AEIOU

T: temperature, trauma

I: infection

P: psychiatric

S: shock, SAH, stroke, space-occupying lesions

A: alcohol

E: electrolytes, epilepsy, encephalopathy

I: insulin (HHS or hypoglycemia)

O: opioids, low oxygen

U: uremia

*check SUGAR on EVERY pt!!

Question 2

Three quick Qs to eval of mental status?

Answer 2

1. Orientation to person, place, time, situation
2. Count backwards from 10 (then serial 7s)
3. Recall of three unrelated objects

Question 3

Glasgow Coma Scale – Eyes

Answer 3

4: spontaneous
3. to verbal command
2: to pain
1: none

Question 4

Glasgow Coma Scale – Verbal

Answer 4

5: oriented or converses
4: confused conversation
3: inappropriate words
2: incomprehensible sounds
1: none

Question 5

Glasgow Coma Scale – Motor

Answer 5

6: obeys commands
5: localizes to pain
4: flexion withdrawal
3: deCORTicate posturing
2: decerebrate posturing
1: none

Question 6

Cushing’s Reflex

Answer 6

increased ICP leading to:

HTN + bradycardia

Question 7

Decorticate Positioning

Answer 7

damage of the descending motor pathways above the midbrain that leads to:

• hyperextension of the legs
• flexion of the arms

(COR - arms flexed over the heart)

Question 8

Decerebrate Posturing

Answer 8

damage to the midbrain and pons leading to:

• hyperextension of the legs
• hyperextension of the arms

Question 9

Oculovestibular Reflex

Answer 9

Normal/Pyschogenic:

• rapid nystagmus AWAY from cold
• slow tonic deviation towards cold

True Coma:

• no nystagmus component
• only slow tonic deviation towards cold

Question 10

Hypoglycemic Coma

• management

Answer 10

• D50W
• thiamine 100 mg, IV

Question 11

Benzodiazepine Coma

• management

Answer 11

Flumazenil IV

• first, 0.2 mg over 30s
• then, 0.3 mg over 30s
• then, 0.5 mg over 30s, every 1 minute

*maximum total dose = 3 mg

Question 12

Opioid Coma

• management

Answer 12

Naloxone/Narcan IV, IM, SubQ

• 0.4 to 2 mg
• repeat every 2-3 min

Question 13

Anticholinergic Coma

Answer 13

eg: Jimson Weed, Amanita muscaria, Scopalamine, Benadryl

Physostigmine

• 0.5-2 mg, IV
• can repeat every 10-30 minutes, PRN
• cholinergic SE: vomiting, diarrhea, abd cramps, diaphoresis

* if QRS > 100 ms, give NaHCO2

Question 14

Increased Intracranial Pressure Coma

Answer 14

• Intubate
• consider Mannitol 0.5-1 gram/kg, IV

Question 15

Eyeballs and Eyelids in

Psychogenic versus True Coma

Answer 15

Psychogenic Coma

• Bell’s Phenomenon: eyes deviate upwards, only sclera will show
• Occulovestibular Reflex: rapid nystagmus AWAY from cold stimulus INTACT

True Coma

• lids close slowly and incompletely
• Occulovestibular Reflex: tonic deviation towards cold stimulus only (no rapid nystagmus)