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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Clinical signs of coma

A
  • hypnosis
  • amnesia
  • areflexia
  • analgesia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What anatomical structures are involved in consciousness?

A
  • Reticular Activating System
  • Brain stem
  • Cerebral Cortex
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What’s NMDA receptor?

A

excitatory neurotransmitter receptor e.g. glutamate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Common causes of altered consciousness

A
  • neurological
  • toxicological
  • endocrine/metabolic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What GCS would be a cut-off for intubation?

A

GCS of 8 or lower

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What if a patient is ‘snoring’?

A

May indicate airway obstruction - may need to open the airway

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are examples of adjunct airway devices?

A

Adjuncts:

  • oropharyngeal
  • nasopharyngeal
  • supraglottic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Examples of definitive airway devices

A

Definitive

  • endotracheal tube
  • cuffed tracheostomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What if reduced LOC patient is vomiting?

A
  • head tilt
  • suction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
Component of 'circulatory' assessment in ABCD?
_Assess:_ - pulse - BP - cap refill time - ECG
26
Treatments used in **'C'** component of ABCD
* IV access * IV fluids -\> to increase venous return to the heart * +/- inotropes * anti-arrhythmias * if hypertension -\> treat underlying cause (e.g. increased ICP)
27
Why 'hypertension' may be needed?
To maintain perfusion to the brain
28
***Glasgow Coma Score***
29
Two scales used to assess consciousness (just name)
* AVPU * GCS
30
Possible causes for **small** and **reactive pupils**
_Small but reactive pupils:_ * metabolic encephalopathy * midbrain herniation
31
**Pinpoint** and **fixed** pupil - what are the possible causes?
_\* fixed -_ _non reactive_ _to light_ * pontaine lesion * opiates * organophospahtes (chemicals)
32
**Dilated** and **reactive pupils** - causes
_Dilated and reactive_ * metabolic * midbrain * ectasy * amphetamines
33
**Dilated** and **fixed pupils** - causes
**Dilated** and **fixed** pupils - ictal - hypoxia - ischaemia - hypothermia - anticholinergics
34
**Unequal,** but **small** and **reactive** pupils - a potential cause
*Horner's* syndrome
35
unequal, dilated and fixed pupils - potential causes
* III n. palsy * uncal herniaiton (transtentorial brain herniation)
36
Components of '**D**' assessment (ABCD)
* Pupils * glucose level (check BM!) * rash * pyrexia/ temperature * trauma evidence * 'what's in the pockets'?
37
1st line blood investigations unconscious patient
* Glucose * ABG * Electrolytes: U&Es, calcium, magnesium * LFTs * TFTs * Poisons: Paracetamol, Salicylate levels * FBC, CRP
38
What (other than blood) Ix to do in the unconscious patient?
- urine - x-ray - CT head
39
What's things (2) do we need to consider in the alcoholic patient treatment?
* **Wernicke's encephalopathy** may be there -\> thiamine (B1 vitamin) deficiency * treat alcohol withdrawal symptoms -\> benzodiazepines
40
The classic triad of **Wernicke's encephalopathy**
Wernicke's encephalopathy: thiamine/vitamin B1 deficiency Triad: ophthalmoplegia, ataxia, memory loss
41
Treatment for opioid overdose
***Naloxone*** 200 mcg IV
42
The antidote _for_: **Tricarboxylic acid**
**Bicarbonate**
43
Antidote for **B-blockers**
Glucagon
44
Antidote for **iron**
Desferrioxamine
45
Antidote for methanol, ethylene glycol
Glucagon
46
Antidote for Paracetamol
N-acetylcysteine
47
The antidote for Carbon monoxide
Oxygen
48
Antidote for ***Benzodiazepines***
Flumazenil
49
Antidote for opiates
***Naloxone***
50
Do we give ***Flumazenil*** to the patient who comes with **OD** of unknown drugs?
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
Some atypical presentation of SAH
* may have all signs of meningitis (hours/days) * 3rd and 6th nerve palsy * papilledema/ subhyaloid haemorrhage
52
Is SAH always +ive on CT scan?
Smaller bleeds may be -ve on CT -\> check LP (xanthochromia)
53
What two scales are used to assess the severity of SAH?
54
Management of SAH
- BP management - enough to perfuse the brain but not too much to make bleeding worse - ***Nimodipine*** - to prevent cerebellar vasospasm
55
How do we reduce ICP in acute situation? (2)
* ***Mannitol*** 0.5g/kg OR * ***Hypertonic saline***