Coma, hydrocephalus, head injury

Question 1

Outline GCS

3-15

Answer 1

EYES (4 spontaneous, 3 speech, 2 pain, 1 nil)

VERBAL (5 orientated, 4 confused, 3 words, 2 sounds, 1 nil)

MOTOR (6 obeying, 5 localising, 4 withdrawing, 3 flexing, 2 extending 1 nil)

<8 traditionally coma (also criteria for intubation as unable to protect own airway)

Introduce and ask place year and month, ask to squeeze hand or stick out tongue, apply central pain (trapezius, supra-orbital), apply peripheral pain (nail bed pressure)

Question 2

Aetiology of coma?

Answer 2

Pathophysiology - brainstem, bilateral thalamic lesions, diffuse cortical lesion

Intracranial: may be associated with lateralising signs): head injury, epilepsy, infarction (large hemisphere stroke with secondary brainstem compression or brainstem stroke), haemorrhage (intraparenchymal, pituitary, subarachnoid, subdural, extradural), tumour, infection (abscess, empyema, encephalitis, meningitis), hydrocephalus, HIE

Extracranial: usually not associated with lateralising signs): diabetic complications (hypoglycaemia or hyperosmolar non-ketotic coma), poisons and overdose, organ failure, ionic disturbance

Question 3

Investigations for coma?

Answer 3

Metabolic screen: U+E, FBC, glucose, LFT, ABG, drug screen, Ca, PO4, Mg, thiamine, B12, folic acid, amylase, cortisol, TFT, porphyrin

CT + or - MRI to further delineate findings

LP if CT negative

EEG if still no diagnosis - unusual (HSVE, metabolic encephalopathy, subclinical seizures / non-convulsive status)