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Emergency Medicine > Coma > Flashcards

Coma Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is a coma?

A

Unrousable and unresponsive

Quantified using the GCS

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2
Q

What are some metabolic causes of coma?

A

Drugs/poisoning - CO, alcohol, tricyclics

Hypoglycaemia/hyperglycaemia

Hypoxia/CO2 narcosis (COPD)

Septicaemia

Hypothermia

Myxoedema/Addisonian Crisis

Hepatic/uraemic encephalopathy

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3
Q

What are some neurological causes of coma?

A

Trauma

Infection - encephalitis, malaria, typhoid, typhus, rabies, trypanosomiasis

Tumour

Vascular - stroke, haemorrhage, hypertensive encephalopathy

Epilepsy

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4
Q

What is the immediate management for a patient with a reduced GCS?

A

ABC

  • consider intubation if GCS <8
  • treat seizures
  • give o2 as req.
  • protect c-spine

Check BM - give 200ml 10% dextrose IV stat if hypoglycaemia

IV thiamine if wernicke’s encephalopathy suspected

IV naloxone - opiate tox
IV flumazenil - benzodiazepine tox

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5
Q

What is key on examination for a patient with reduced GCS?

A 
Vital signs - full set + temperature
Signs of trauma
Stigmata of other illness - liver disease/alcoholism etc.
Skin
Smell breath - alcohol, hepatic fetter, ketosis, uraemia
Opisthotonus
Meningism
Pupils - size, reactivity, gaze
Heart/lung
Abdo/rectal
Foci of infection - abscess, bites, middle ear infection
Absence of signs
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6
Q

What signs of trauma may you assess for in a patient with reduced GCS?

A 
Haematoma
Laceration
Bruising
CSF or blood in nose/ear
Fracture of skull - step deformity
Subcutaneous emphysema
Panda eyes
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7
Q

What signs may you see on the skin in a patient with reduced GCS?

A

Cyanosis
Pallor
Rash
Poor turgor

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8
Q

What is opisthotonus and what is it indicative of?

A

Spasm of the muscles causing backwards arching of the head neck and spine.

Indicative of meningitis or tetanus

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9
Q

What would you look for on examination of the heart and lungs in a patient with reduced GCS?

A 
BP
Murmurs
Rubs
Wheeze
Consolidation
Collapse
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10
Q

What would you look for on abdo/rectal exam in a patient with reduced GCS?

A 
Organomegaly
Ascites
Bruising
Peritonism
Melaena
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11
Q

What things would you ask in a quick collateral history for a patient with reduced GCS?

A

Onset - abrupt or gradual?

How found - suicide note? seizure?

Injury? - C-Spine immobilisation

Recent complaints - headache, fever, vertigo, depression

Recent medical hx - sinusitis, otitis, neurosurgery, ENT operation

PMH - diabetes, asthma, hypertension, cancer, epilepsy, psychiatric illness

Drug/toxin exposure? Travel?

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12
Q

If the diagnosis is unclear in a patient in a coma, what is your management plan?

A

Treat the treatable - BM, O2 etc.

Routine biochemistry, haematology, thick films, blood cultures, blood ethanol and drug screens

Arrange CT head and LP if req.

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13
Q

Outline the flowchart for managing a coma

A 
ABC of life support
             v
Gain IV access
             v
Stabilise the C Spine
             v
Take blood glucose
             v
Control seizures
             v
Treat potential causes - O2, glucose, drugs etc.
             v
Brief collateral hx and examination
             v
Investigations
             v
Reassess
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14
Q

What investigations may you do if unclear why a patient is in a coma?

A

ABG, FBC, U&E, LFT, CRP, Ethanol, Tox screen, drug levels

Blood culture, urine culture, consider malaria

CXR, CT head

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15
Q

What are the parts of the GCS?

A

Motor Response
Verbal Response
Eye Movement

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16
Q

Define how motor response is rated in the GCS?

A 
6 - Obeys commands
5 - Localise to pain
4 - Withdraw from pain
3 - Flex to pain
2 - Extend to pain
1 - No response to pain
17
Q

Define how the verbal response is rated in the GCS

A 
5 - Oriented to time, place and person
4 - Confused conversation
3 - Inappropriate speech
2 - Incomprehensible sounds
1 - None
18
Q

Define how eye opening is rated in the GCS

A

4 - Spontaneous
3 - In response to speech
2 - In response to pain
1 - None

19
Q

How can you categorise GCS scores?

A

<8 - severe injury - consider airway protection
9-12 - moderate injury
13-15 - minor injury

20
Q

Describe what happens in flexion to pain and what is the name of the posture?

A

Decorticate posture

Arms bent inwards on chest
Thumbs tucked in a clenched fist
Legs extended

21
Q

What does flexion to pain indicate about the injury?

A

It is above the level of the red nucleus in the midbrain

22
Q

What is the posture for extension from pain and describe it?

A

Decerebrate posture

Adduction and internal rotation of the shoulder
Pronation of the forearm

23
Q

What does extension from pain indicate about the injury?

A

Midbrain damage below the level of the red nucleus

24
Q

Pathology in which 2 locations may lead to altered consciousness?

A

1 Diffuse bilateral cortical dysfunction

2 Damage to ascending reticular activating system (located throughout brainstem) - this can be direct or indirect

25
Q

Give an example of direct and indirect causes of brainstem damage

A

Direct - pontine haemorrhage

Indirect - compression from transtentorial or cerebellar herniation due to a mass or oedema

26
Q

What are some examples of pathological breathing patterns?

A

Cheyne Stokes - brainstem lesions or compression

Hyperventilation - acidosis, hypoxia or (rarely) neurogenic

Ataxic/Apneustic (breath holding) - severe brainstem lesion

27
Q

What are the parts of the eye examination for a patient in a coma?

A

Visual fields
Pupils
Extraocular movements
Fundi

28
Q

What may be seen on examination of visual fields in a patient in a light coma?

A

No blink in one field - indicate hemianopia and contralateral hemisphere lesion

29
Q

What may be seen on pupil examination in a patient in a coma?

A

Normal direct and consensual reflexes - intact midbrain

Midposition non reactive ± irregular = midbrain lesion

Unilateral dilated and unreactive = 3rd nerve compression

Small reactive - pontine

Horners syndrome - ipsilateral medulla or hypothalamus lesion, may precede uncle herniation

30
Q

What do you look for on examination of the funds in a patient in a coma?

A

Papilloedema
Subhyaloid haemorrhage
Hypertensive retinopathy
Signs of other disease

31
Q

How do you test extra ocular movements in a patient in a coma?

A

Observe resting position and spontaneous movement

Test vestibule-ocular reflex with dolls head manoeuvre or ice water calorics

If VOR is normal, most of the brainstem is likely unaffected

32
Q

What is dolls head manoeuvre?

A

Eyes should look at same point in space when head move quickly laterally or vertically

33
Q

What is ice water calorics?

A

Normal if eyes deviate to cold ear with nystagmus to the other side

34
Q

How do you assess for CNS asymmetry in a patient in a coma?

A

Assess tone, spontaneous movements and reflexes

Test for hemiplegia - raise both arms and compare how they fall under gravity:
- if one falls faster than the other, indicate cortical dysfunction

Emergency Medicine (9 decks)

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