COMA

Question 1

MANAGEMENT

Answer 1

POC Glucose

UNIVERSAL ANTIDOTES:
Dextrose-50 mL of D50W (or glucagon 1mg IM)
Oxygen
Narcan (0.4 mg IV / IN / IM up to 2 mg, up to 10 mg if fentanyl or methadone)
Thiamine (100 mg but make sure to give with the dextrose

INVESTIGATIONS
CBC
Electrolytes
Extended Lytes
Cr
Urea
LFTs
NH3
TSH
Cortisol
VBG
Blood Cultures
U/A
Urine Cultures

CT Head

Lumbar Puncture

MRI ahead

EEG

Question 2

DOCUMENTATION

Answer 2

Clinical Features: Toxic-Metabolic Coma

Lack of focal neurological findings
Pupillary responses equal
Spontaneous movement OR reflex posturing
Movements are symmetric with NO hemiparesis
Symmetric muscle stretch reflexes

Clinical Features: Supratentorial Lesions

Progressive hemiparesis
asymmetric muscle tone
Asymmetric stretch reflexes
Asymmetric extensor or flexor postures

Clinical Features: Increased ICP
Cushing’s Reflex: hypertension and bradycardia in a comatose patient

Clinical Features: Infratentorial Lesions
Abrupt coma
Abnormal extensor posturing
Loss of pupillary reflex
Loss of EOM

Question 3

DDx: Global CNS Depression

Answer 3

R/o Seizure

Drug Intoxication: Opioids, Benzodiazepines, Barbituates, EtOH; B-Blockers, TCA, ASA, Acetaminophen, Digoxin

Infection: Sepsis, Meningitis, Encephalitis

Metabolic: Hypoxia, Hyper/ Hyponatremia, Hypercalcemia, Hypoglycemia, Hyperosmolar State, Hypothyroidism, Addison’s Disease, Hypoxic Encephalopathy, Metabolic Encephalopathy, Hypertensive Encephalopathy, Hepatic Encephalopathy, Uremia, Wernicke’s, Carbon Dioxide Narcosis, Carbon Monixide, Cyanide

Structural: Hemorrhage, Infarction (both hemispheres, brainstem), Neoplasm.

Direct Trauma: Diffuse axonal injury, subdural hematoma, Epidural hematoma