Unconsciousness Flashcards
You are the medical SHO oncall overnight. The medical team have been fastbleeped to A&E resus by the nurse in charge to see a 58 year old man, who self discharged this morning. He has been brought back in by an ambulance crew who found him drowsy and confused, with reduced responsiveness at a bus stop. The medical registrar is busy with an arrest call and has asked you to review the patient and call him if there are any problems. His GCS is 9/15 (E2, V3, M4).
The man has no fixed abode and was admitted 3 days ago with a similar presentation. He has no known medical history and has no known next of kin. He had remained in hospital due to social reasons before his self discharge. He smells strongly of alcohol and there is evidence that he may have vomited.
On your way down to review the patient, what differential diagnoses would you consider?
Infective - meningitis, encephalitis,
Neoplastic / Neuro - space occupying lesion, post-ictal
Vascular - intracranihal haemorrhage, large territory infarct
Inflammatory - vasculitis
Trauma - subdural / epidural haematoma
Electrolyte/Endocrine - hypoG, hypo/hyperN, hypo/hyperCa
Drugs - alcohol (intoxication/withdrawal), opiates
Metabolic - hepatic encephalopathy, Wernicke’s encephalopathy
Degenerative
How would you initially assess and manage this patient?
ABCDE approach
A
- Look for signs of obstruction (vomiting)
- Reduced responsiveness - be very mindful of obstruction
- If airway compromised, nasopharyngeal airway for the time being or Guedel if tolerated
- If the pt can tolerate these, I would be concerned about the ongoing airway patency, so I would fast-bleep the ITU registrar
- Failing this, I would put out a crash call (need immediate assistance)
B
- Continuous SpO2 monitoring, Check RR
- Give high flow oxygen
- Look, listen, feel - bilateral chest expansions, listen for bilateral air entry, wheeze, crepitations, silence (asthma, pulmonary oedema, tension pneumothorax, massive haemothorax) must immediately identify these conditions during B and treat
C
- Continuous monitoring for HR, BP
- Check CRT (peripheral, central)
- 12-lead ECG
- 1-2x IV access + take bloods + VBG (lactate, BM)
- Assess fluid status (JVP, oedema) and give IV fluids
- Catheter to monitor** UO**
Disability
- Blood sugar
- Temperature
- GCS / AVPU
- Check pupils
E
- Expose appropriately and examine for signs of external injury, track marks, infection
Remember - if GCS < 8»_space; INTUBATE
At what GCS is it advised to intubate?
8 and less
You are handed an ABG on arrival to the resus department, the results of which are as follows:
pH 7.36 pCO2 5.6 pO2 35 Na 130 K 5.7 Glu 1.2 HCO3- 25.
What is the cause of the presentation and what would you do now?
The patient is severely hypoglycaemic.
- Make sure bloods have already been taken
- Give 100 mL 20% dextrose IV over 15 min
- If IV access not possible, 1mg of IM glucagon
- Pt should show signs of improvement within 10 minutes
- Further IV glucose should not be given before repeating the blood glucose
- Once the pt alert enough, give carbohydrate rich food
The scenario also mentioned that the pt strongly smelled of alcohol. I would make sure that I have given IV Pabrinex to reduce the risk of precipitating Wernicke’s encephalopathy
What are the common causes of hypoglycaemia?
Exogenous drugs
* Insulin, oral hypoglycaemics (sulfonylureas - gliclazide)
* Alcohol - binge, no food
* Salicylates (aspirin poisoning)
P
- Pituitary insufficiency
Liver failure
Addison’s disease
Islet cell tumours (insulinoma)
Non-pancreatic neoplasms due to overproduction of IGF-2
- E.g. Fibrosarcomas
in non-diabetics, you must EXPLAIN mechanism
In the A&E department you are unable to give IV glucose as access is incredibly difficult. You ask the nurse to give IM glucagon, however, there is no response in blood glucose. What is the cause of this patient’s hypoglycaemia?
Glucagon is a hormone that induces conversion of glycogen to glucose in the liver (glycogenolysis), thereby raising the blood glucose level
The fact that the glucagon is not working suggests that the process of glycogenolysis is not working. Given the patient’s history, it’s most likely that glycogenolysis is inhibited due to the excess alcohol that the liver has to metabolise.
What information should be given to patients with diabetes who drink alcohol?
Patients should be informed that alcohol can increase the risk of hypoglycaemic episodes.
Why?
Despite containing carbohydrates and initially raising blood sugars on consumption, alcohol inhibits the liver’s ability to release glucose into the blood. This impairment can last for several hours after drinking alcohol.
- Not drinking on an empty stomach can decrease the risk of hypoglycaemia.
- Taking additiona carbohydrates before going to sleep at night after drinking alcohol also reduces the risk.
What information should be given to patients with diabetes about hypoglycaemic episodes?
Diabetic pts with episodes of hypoglycaemia need education in:
* Nutrition
* Checking glucose levels at home
* Early signs and symptoms of hypoglycaemia
* Recognition of early Sx is paramount for self-treatment
* Pts must inform the DVLA if they drive and take insulin/sulphonylureas
* Pts should be encourage to always measure their BM before driving
* If less than 5.0 mmol/L > should not drive
You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the acute medicine handover.
Situation: I have a 58 year old man who has presented with a low GCS (9/15) secondary to hypoglycaemia. The hypoglycaemia has been caused by acute excessive alcohol consumption.
Background: This patient self-discharged from hospital this morning having presented similarly three days ago.
Assessment: There has been no response to IM glucagon and IV access has not been possible. He remains drowsy with a low GCS and I am concerned about his airway given his level of arousal.
Recommendations: He needs urgent IV access. I will inform the ITU SPR about this man as they may be able to help with securing IV access and they will need to assess him from an airway point of view. He may need to be managed initially in a high dependency unit. He will need input in the long term to review his alcohol consumption and ways to address this.
