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Y3 Lecture weeks > Assessment of patient with reduced consciousness > Flashcards

Assessment of patient with reduced consciousness Flashcards

1
Q

Definition of coma

A

Coma is a total absence of awareness of both self and the external environment

*those who do not open eyes to pain, do not move spontaneously, do not form recognisable words

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2
Q

Clinical signs of coma

A
  • hypnosis
  • amnesia
  • areflexia
  • analgesia
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3
Q

What anatomical structures are involved in consciousness?

A
  • Reticular Activating System
  • Brain stem
  • Cerebral Cortex
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4
Q

What’s NMDA receptor?

A

excitatory neurotransmitter receptor e.g. glutamate

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5
Q

What’s needed to maintain consciousness?

A
  • anatomical structures: reticular activating system, brain stem, cerebral cortex
  • biochemicals: GABA-A, NMDA, noradrenaline
  • cerebral metabolism
  • cerebral blood flow
  • co-ordinated electrical activity
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6
Q

Common causes of altered consciousness

A
  • neurological
  • toxicological
  • endocrine/metabolic
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7
Q

What is the most important in making the diagnosis of the cause of reduced LOC?

A
  • history -> the most important
  • PMH
  • examination
  • bloods -> only helpful in small fraction of cases
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8
Q

UNCONSCIOUS - memonic for differentials in unconscious patient

A

U - units of insulin

N - narcotics (e.g. opioids)

C - convulsions

O - oxygen = hypoxia

N - non - organic (e.g. functional vs non-functiona;)

S - stroke

C - cocktail (overdose)

I - ICP

O - organism

U - urea

S - shock

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9
Q

COMA - memonic for differentials in unconscious patient

A

C- carbon dioxide or carbon monoxide (excess)

O - overdose

M - metabolic

A - apoplexy (unconsciousness as a result of cerebral haemorrhage or stoke)

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10
Q

What GCS would be a cut-off for intubation?

A

GCS of 8 or lower

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11
Q

What’s the first component of the assessment of the unconscious patient?

A

Airway

  • assess
  • call anaesthetics if needed
  • temporary measured e.g. Gadel
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12
Q

What if a patient is ‘snoring’?

A

May indicate airway obstruction - may need to open the airway

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13
Q

Oropharyngeal airway:

  • advantages and usual use
A

Oropharyngeal airway

  • Easy to insert and use
  • No paralysis required
  • Ideal for very short procedures
  • Most often used as bridge to more definitive airway
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14
Q

Laryngeal mask

  • advantages / disadvantages
  • use
A

Laryngeal mask

  • Widely used
  • Very easy to insert
  • Device sits in pharynx and aligns to cover the airway
  • Poor control against reflux of gastric contents
  • Paralysis not usually required
  • Commonly used for wide range of anaesthetic uses, especially in day surgery
  • Not suitable for high pressure ventilation (small amount of PEEP often possible)
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15
Q

Tracheostomy

  • use
  • advantages and disadvantages
A

Tracheostomy

  • Reduces the work of breathing (and dead space)
  • May be useful in slow weaning
  • Percutaneous tracheostomy widely used in ITU
  • Dries secretions, humidified air usually required
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16
Q

Endotracheal tube

  • use
  • advantages
A

Endotracheal tube

  • Provides optimal control of the airway once cuff inflated
  • May be used for long or short term ventilation
  • Paralysis often required
  • Higher ventilation pressures can be used
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17
Q

What do we need to check and why after insertion of endotracheal tube?

A

Errors in insertion may result in oesophageal intubation (therefore end tidal CO2 usually measured)

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18
Q

What are examples of adjunct airway devices?

A

Adjuncts:

  • oropharyngeal
  • nasopharyngeal
  • supraglottic
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19
Q

Examples of definitive airway devices

A

Definitive

  • endotracheal tube
  • cuffed tracheostomy
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20
Q

What is the advantage of cuffed tracheostomy over the endotracheal tube in the management of the unconscious patient in A&E?

A

With endotracheal tube pt can aspirate on food/drinks they have eaten

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21
Q

What if reduced LOC patient is vomiting?

A
  • head tilt
  • suction
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22
Q

3 ‘Es’ in assessment of BREATHING?

A

Effort, efficacy, effects

  • Effort: RR, accessory muscles
  • Efficacy: cyanosis, spO2, ABGs (pO2 and pCO2)
  • Effects: consciousness
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23
Q

Possible causes of increased RR

A

Increased RR

  • hypoxia
  • brainstem herniation
  • metabolic acidosis
  • OD
24
Q

Possible causes of decreased RR

A

Decreased RR

  • opiate
  • sedative OD
  • head injury
25
Q

Component of ‘circulatory’ assessment in ABCD?

A

Assess:

  • pulse
  • BP
  • cap refill time
  • ECG
26
Q

Treatments used in ‘C’ component of ABCD

A
  • IV access
  • IV fluids -> to increase venous return to the heart
  • +/- inotropes
  • anti-arrhythmias
  • if hypertension -> treat underlying cause (e.g. increased ICP)
27
Q

Why ‘hypertension’ may be needed?

A

To maintain perfusion to the brain

28
Q

Glasgow Coma Score

A
29
Q

Two scales used to assess consciousness (just name)

A
  • AVPU
  • GCS
30
Q

Possible causes for small and reactive pupils

A

Small but reactive pupils:

  • metabolic encephalopathy
  • midbrain herniation
31
Q

Pinpoint and fixed pupil - what are the possible causes?

A

* fixed - non reactive to light

  • pontaine lesion
  • opiates
  • organophospahtes (chemicals)
32
Q

Dilated and reactive pupils - causes

A

Dilated and reactive

  • metabolic
  • midbrain
  • ectasy
  • amphetamines
33
Q

Dilated and fixed pupils - causes

A

Dilated and fixed pupils

  • ictal
  • hypoxia
  • ischaemia
  • hypothermia
  • anticholinergics
34
Q

Unequal, but small and reactive pupils - a potential cause

A

Horner’s syndrome

35
Q

unequal, dilated and fixed pupils - potential causes

A
  • III n. palsy
  • uncal herniaiton (transtentorial brain herniation)
36
Q

Components of ‘D’ assessment (ABCD)

A
  • Pupils
  • glucose level (check BM!)
  • rash
  • pyrexia/ temperature
  • trauma evidence
  • ‘what’s in the pockets’?
37
Q

1st line blood investigations unconscious patient

A
  • Glucose
  • ABG
  • Electrolytes: U&Es, calcium, magnesium
  • LFTs
  • TFTs
  • Poisons: Paracetamol, Salicylate levels
  • FBC, CRP
38
Q

What (other than blood) Ix to do in the unconscious patient?

A
  • urine
  • x-ray
  • CT head
39
Q

What’s things (2) do we need to consider in the alcoholic patient treatment?

A
  • Wernicke’s encephalopathy may be there -> thiamine (B1 vitamin) deficiency
  • treat alcohol withdrawal symptoms -> benzodiazepines
40
Q

The classic triad of Wernicke’s encephalopathy

A

Wernicke’s encephalopathy: thiamine/vitamin B1 deficiency

Triad: ophthalmoplegia, ataxia, memory loss

41
Q

Treatment for opioid overdose

A

Naloxone 200 mcg IV

42
Q

The antidote for:

Tricarboxylic acid

A

Bicarbonate

43
Q

Antidote for B-blockers

A

Glucagon

44
Q

Antidote for iron

A

Desferrioxamine

45
Q

Antidote for methanol, ethylene glycol

A

Glucagon

46
Q

Antidote for Paracetamol

A

N-acetylcysteine

47
Q

The antidote for Carbon monoxide

A

Oxygen

48
Q

Antidote for Benzodiazepines

A

Flumazenil

49
Q

Antidote for opiates

A

Naloxone

50
Q

Do we give Flumazenil to the patient who comes with OD of unknown drugs?

A

Not if we do not know what pt has taken

Flumazenil - the antidote for benzodiazepines

BUT

  • If we do not know what other meds they take, e.g. benzodiazepines for stopping seizures -> we may induce seizures
  • In that case, we would not be able to stop the seizures as we would block benzodiazepines receptors
51
Q

Some atypical presentation of SAH

A
  • may have all signs of meningitis (hours/days)
  • 3rd and 6th nerve palsy
  • papilledema/ subhyaloid haemorrhage
52
Q

Is SAH always +ive on CT scan?

A

Smaller bleeds may be -ve on CT -> check LP (xanthochromia)

53
Q

What two scales are used to assess the severity of SAH?

A
54
Q

Management of SAH

A
  • BP management - enough to perfuse the brain but not too much to make bleeding worse
  • Nimodipine - to prevent cerebellar vasospasm
55
Q

How do we reduce ICP in acute situation? (2)

A
  • Mannitol 0.5g/kg

OR

  • Hypertonic saline

Y3 Lecture weeks (65 decks)

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