Coma

Question 1

Immediate management

Answer 1

Attend to ABC Trauma possible->immobilise the spine Arrange urgent neurosurgical consult Insert IV Perform blood glucose (manage if hyper/hypo) Consider naloxone (0.1mg/kg IV) Assess and monitor pulse, RR, BP, temperature, oximetry ECG Look for signs of convulsion

Question 2

Important past history considerations

Answer 2

Seizures Diabetes Adrenal insufficiency Infection Cardiac Previous similar episodes

Question 3

Examination findings to look for and their considerations

Answer 3

Scalp bruising/hemtatoma->Head injury Inconsistent history, retinal hemorrhage->NAI Fever, seizures->Meningitis, encephalitis Focal neurological, focal seizures, papilloedema, asymmetric pupils->Focal IC pathology Shunted hydrocephalus->Blocked shunt Renal disease->Hypertensive encephalopathy

Question 4

Investigations to consider

Answer 4

full blood examination urea and electrolytes glucose liver function test arterial blood gas urine drug ± metabolic screen urine antigens culture of blood and urine ammonia cortisol coagulation screen ECG

Question 5

Requirements to meet prior to doing LP

Answer 5

No papilloedema No focal neurology or focal seizure Not immediately after a seizure Rousable to full consciousness If not rousable-> >2 with definite neck stiffness and no localising signs

Question 6

Management if Papilloedema or focal neurological/focal seizure

Answer 6

Febrile->give aciclovir + cefotaxime. Consider MRI/CT. No LP Not febrile->MRI/CT; consider aciclovir and cefotaxime if results unclear a to whether infection

Question 7

Management when no +pap, no focal, immediately after seizure

Answer 7

Give paracetamol 20mg/kg once if febrile and consider antibiotics if no improvement in conscious state or recovery X w/i 6 hours

Question 8

Coma flow chart->LP, imaging and antibiotics

Answer 8

Flow chart