APPROACH

1. Transient Causes
o Vasovagal
o Concussion
Seizure
o Orthostatic
o Cardiac rhythm
2. Prolonged Causes
o GI
o Hepatic
o Renal
o Endocrine
o Metabolic
o Pulmonary
o Cardiac
o Heme
o Sepsis
o Neuro
o ETOh/drugs
3. Unconscious now?
o Manage ABC
Coma score < 8 intubate
Hypotension fluids
Glucose administer and check
o Labs, tests
Urine
CT head
EKG, cardiac troponins, CXR
4. Conscious now?
o Transient
Make sure it is syncope
LOC transient and complete
Loss of postural tone?
Recovery complete and spontaneous?
o Yes to these 3 questions -> syncope
Onset
Duration
Standing up from sitting or fluid loss
Orthostatic syncope
o Review BP and meds
o Drop in systolic BP > 20 mmHg and
diastolic BP > 10mmHg within 5 minutes
of standing

o Skin turgor
o Urine output
Trigger, emotional or physical or prodrome
Vasovagal syncope
o No treatment or diagnostic test
Aura
Seizure
o EEG
o Check for secondary causes
o Glucose, CMP, drug, etc.
CT head
o Petit mal, absence, or Grand mal
Palpitations
Cardiogenic syncope
o Cardiac exam
o EKG
o V Tach, A. fib, Long QT, etc.
Trauma
Concussion
o Check for lucid interval
o CT head
o Rule out subdural hematoma
o Confusion, Amnesia, Headache
o Prolonged
Most common causes are metabolic, drugs, EtOH,
cardiac, pulmonary, and neuro
Look for clues in history
Headache Subarachnoid hemorrhage
Uncontrolled HTN CVA
o De-cerebrate or decorticate rigidity
o Facial asymmetry
o Asymmetric pupils
Seizure brain tumor
o Froth, weight loss
Recent EtOH use
o EtOH breath
Drug use
o Needle marks, pupils
SOB, recent MI, CP Cardiac failure
o Hypotension, murmur
SOB PE, effusion, pneumothorax
o Decreased pulse ox, breath sounds
Uncontrolled/New onset DM DKA

o Ketone breath
Fatigue/cold intolerance myxedema
o Hypothermia, bradycardia
Swelling Renal failure
Chronic EtOh, ascites, GI bleed Liver failure
o Caput medusae, gynecomastia
Recent diarrhea, dehydration gastroenteritis
Bleeding, multiple organ failure DIC
Untreated infection, low BP Septic Shock
o Fever, hypotension, tachycardia

 Different Types of Shock

o Cardiogenic
Low cardiac output
High PCWP preload
High SVR afterload as compensatory method
MI, Arrhythmia, Cardiac Failure
o Obstructive
Low cardiac output
Normal/Low/High PCWP
Initially low or normal in PE and pleural effusion
In cardiac Tamponade, PCWP equalizes with right
atrial and right ventricular pressures
High SVR Afterload as compensatory method
PE, Tamponade, Pneumothorax
o Hypovolemic
Low cardiac output
Low PCWP preload (lack of fluid)
High SVR Afterload as compensatory method
GI loss, Dehydration, Hemorrhage
o Distributive
High cardiac output
Low PCWP preload
Low SVR Afterload
Sepsis, SIRS, Neurogenic, Anaphylactic
Tissues are trying to get as much oxygen (by way
of blood) to get rid of toxins. Massive dilatation
leads to low SVR output and increased cardiac
output as compensatory method
o Loss of consciousness occurs when ascending reticular
activating system is not intact.
Syncope/Transient loss of consciousness
1. Vasovagal syncope
a. Occurs when patient is erect
b. Prodrome
c. Nausea
d. Pallor
e. Lightheadedness
f. Diaphoresis
g. Sometimes no aura at all
h. Causes

i. Vagal surge = vagal tone increases and causes

syncope
2. Orthostatic
a. Occurs from supine to standing position
b. Lightheadedness
c. Causes
i. Due to loss of fluid from low fluid intake,
recent diarrhea, diuretics, heat loss, etc
d. Lab/Physical Exam
i. Drop in systolic more than 20 and diastolic
more than 10 within 5 minutes of getting up
from supine to standing
3. Cardiogenic
a. Occurs in any position
b. Causes
i. HOCM
ii. Aortic Stenosis
iii. Can be no other symptoms
iv. Lightheadedness
v. Palpitations
c. Lab/Physical Exam
i. Sick sinus syndrome
ii. Brady-Tachy syndrome
iii. Long QT syndrome (hereditary or acquired)
1. Due to erythromycin
2. Or hypomagnesaemia/hypocalcemia

3.
iv. HOCM
4. Neurogenic
a. Occurs in any position
b. Seizures/activity, aura/stare
c. Post ictal weakness/paralysis
d. Focal neurologic weakness/numbness
e. Causes
i. TIA
ii. Seizures
Concussion

Recent trauma
Headache
Confusion
Retrograde amnesia
Antegrade amnesia
Temporary LOC Lucid Interval Prolonged loss of
consciousness (lucid interval)
Complications
o Post concussion syndrome:
Post concussion headaches
Post concussion epilepsy
Post concussion encephalopathy
C. Coma (prolonged loss of consciousness)
o Stupor = decreased level of consciousness, awareness or
attention that requires very vigorous stimulation
o Coma = can not be woken up, below 8 = Intubate

o Sign of brainstem dysfunction ^

1. Cerebrovascular accident (Hemorrhage)
a. Subdural hematoma
1. Causes
a. Trauma
b. Bleeding disorder
c. Cocaine/Amphetamine
d. Prescription meds like warfarin or blood
thinners
b. Epidural hematoma
c. Subarachnoid hemorrhage
i. Signs and symptoms of raised ICP
1. Headache, especially when straining or early in
the morning
2. N/V
3. Stiff neck
4. Papilledema
5. Risk factors for hemorrhage
6. Cushing Triad:
a. Bradycardia
b. HTN
c. Hypopnea
ii. Lab/Physical Exam
1. CT scan to make sure theres no herniation

a.
2. MRI
3. Lumbar Puncture
a. Clear
b. Blood drop (traumatic tap)
c. Red disappears and changes to yellow =
xanthochromia, positive sign for
subarachnoid hemorrhage
iii. Risk Factors
1. HTN
2. DM
3. Smoking
d. Most common site causing coma = vertebral basilar
system
e. Causes focal neurologic deficits
i. Cranial nerves and brainstem
1. Location

a. 4 structures in midline beginning with M

i. Motor pathway
ii. Medial lemniscus
iii. MLF
iv. Motor nuclei
b. 4 motor nuclei in midline are divisors of
12 (3,4,6,12)
i. 5, 7, 9, and 11 are lateral
ii. CN 1, 2 have their own thing
c. 4 structures to the side (lateral) and
begin with S
i. Spinocerebellar
ii. Spinothalamic
iii. Sensory nucleus of CN5
iv. Sympathetic pathway
d. 4 CN in Medulla, 4 in pons, 4 above pons
e. Weakness contralateral to CN = LMN
lesion of CN
f. Weakness ipsilateral to CN = UMN lesion
of CN
2. Blood Supply
a. Weber Syndrome
i.

ii. Eye is down and out (CN III/IV)

iii. Contralateral weakness
iv. Contralateral vibration/position
sense loss
b. Medial Pontine Syndrome:

i.

ii. Cant look to the side of the lesion

(CN6)
iii. Contralateral weakness
c. Lateral Pontine Syndrome
i.

ii. Horner syndrome due to

sympathetic loss
1. Ptosis, miosis, anhydrosis
iii. Ipsilateral face droop (CN VII) only
lower half
iv. Loss of corneal reflex
v. Nystagmus and vertigo (CN VIII)
vi. Contralateral weakness
d. Medial Medullary Syndrome
i. Tongue deviated to same side
ii. Contralateral weakness
iii. Contralateral vibration/position
sense loss
e. Lateral Medullary Syndrome (PICA
Syndrome) (Wallenbergs)

i. Hoarseness
ii. Dysphagia
iii. Contralateral pain and temperature
loss (Spinothalamic)
iv. Horners syndrome
ii. Frontal Lobe = Personality change
iii. UMN = Spastic paralysis, LMN = Flaccid
iv. Facial asymmetry
1.

a. Bells Palsy = complete paralysis of the

entire half of face
b. Lower half of face paralyze = UMN lesion
v. Aphasia
vi. Slurred speech
vii. Diplopia
viii. Dysphagia
ix. Upper extremity weakness
x. Lower extremity weakness
xi. Numbness
2. Cerebrovascular accident (Infarction)
a. Caused by hypoperfusion
b. Risk factors
i. A. Fib
ii. Hyperlipidemia
iii. DM
iv. Smoking
v. Clotting disorders
c. Lab/Physical Exam
i. CT head (sometimes misses infarction in early
stages)
ii. MRI

iii. EKG
iv. Trans-esophageal Echo
v. Clotting studies
d. Treatment
i. Thrombolytic therapy
ii. Heparin
iii. ASA/Aggrenox
iv. Control risk factors
v. Anticoagulation
3. Acute Cardiac Failure
a. Chest pain
b. Dyspnea
c. Hypotension
d. Tachycardia
e. Palpitations
f. Oliguria
g. Cause
i. MI
1. Squeeze, tightness, radiate to left arm
2. Older, male, DM, CKD, etc
3. Cardiogenic shock
ii. Aortic Dissection
1. Cardiogenic shock
iii. Hemodynamically significant PE
1. Obstructive shock
2. If a patient has no risk factors like surgery or
immobilization then get lab evaluation for
Protein C & S deficiency, anti thrombin, and
Factor V Leiden mutation
iv. Pericardial Tamponade
1. Obstructive shock
v. Arrythmias
1. Cardiogenic shock
h. All of these cause massive cerebral hypoperfusion,
leading to coma
i. Lab/Physical Exam
i. EKG
ii. Troponins
iii. CK-MB
iv. CT chest
v. Echocardiogram
4. Respiratory failure
a. Chest pain
b. Dyspnea
c. Hypotension
d. Tachycardia

e.
f.
g.
h.

Hypoxia
Use of accessory muscles of respiration
Cyanosis
Causes
i. Upper airway obstruction from angioedema or
status asthmaticus
ii. COPD exacerbation
iii. Pneumothorax
iv. Pleural effusion
v. PE
vi. ARDS
i. Cerebral hypo-oxygenation causes injury
j. Wont breathe = CNS issue
k. Cant breathe = Airway/Pleura/wall
l. Cant breathe enough = Lungs
m. Lab/Physical Exam
i. Hypoxic PO2 < 60 mmHg
ii. Hypercapnic pCO2 > 45mmHg
iii. CXR
iv. ABGs
1.

2. ROME = Respiratory opposite, metabolic equal

(lol this mnemonic)
a. Respiratory = pH/pCO2 in opposite
directions
b. Metabolic = pH/HCO3 in the same
direction (if compensating)
v. CT chest
5. Metabolic Acidosis

a.

b. Increased acid production (DKA, Lactic Acidosis,

salicylate overdose)
i. Anion gap > 12 (Na (Cl + HCO3))
c. Decreased acid elimination (Renal Tubular
Acidosis/CKD)
i. Anion gap normal or increased
d. Loss of HCO3 (severe diarrhea)
i. Anion gap normal
6. DKA
a. New onset DM or uncontrolled DM patients
i. Lack of insulin
ii. Infection
iii. Acute Stress
iv. Gastroenteritis
b. Hyperglycemia
i. Osmolarity is very high, glucose drives water out to
kidneys
ii. Causes polyuria/polydipsia/dehydration
c. Nausea/vomiting and abdominal pain
i. Due to paralytic ileus that results from acidosis
d. Fruity breath (late finding)
i. Due to buildup of ketones
e. Altered mental status, stupor coma
i. Due to metabolic acidosis leading to hypooxygenation
f. Lab/Physical Exam
i. BMP and ABGs

1.

a. Na down due to pseudohyponatremia

(excess glucose makes it look like
hyponatremia)
b. HCO3 down due to metabolic acidosis
c. BUN and creatinine may be normal but
can go up
ii. Urine ketones
g. Treatment (numbers are not necessary to know)
i. FLUIDS
1. Normal Saline at the beginning
2. Switch to D5 .45% normal saline when glucose
is < 200
3. Keep potassium at 4.5 meq/dL
ii. IV Insulin
1. .1 u/kG
2. Lower plasma glucose by 50-70g/dL/hr
(gradually)
3. Switch to subcutaneous insulin when glucose is
< 200
iii. HCO3 (not always used)
1. Use when pH is very low, < 6.9
7. Lactic acidosis
a. Lactate builds up due to anaerobic metabolism
b. Causes
i. Enhanced catabolic rate:
1. Sepsis
2. End stage organ failure
3. Rhabdomyolysis
ii. Increased toxins:
1. Metformin
2. Statins

iii. Enhanced metabolic rate:

1. Seizures
a. Causes a lot of muscle action resulting in
catabolic state
2. Hyperthermia
3. Malignancy
a. Metastatic cancer all over the body can
produce excess lactic acid
c. Lab/Physical Exam
i. Increased lactic acid
ii. AG Metabolic acidosis
d. Treatment
i. Fluids
ii. Treat underlying pathology
8. Hypothyroidism is another cause due to thyroid coma
9. Adrenal insufficiency is another cause due to shock
10. Alcohol intoxication
a. Main mechanism is CNS depression causing respiratory
acidosis, but can also be due to alcoholic
ketoacidosis/ketosis
b. Also causes peripheral vasodilation Hypotension
cardiogenic shock coma
c. Slurred speech
d. Nystagmus
e. Blurry vision
f. N/V
g. Hyperventilation (secondary to ketosis)
h. Hypoventilation (secondary to respiratory depression)
i. Stupor Coma
j. Chronic Alcohol history clues:
i. Hepatomegaly
ii. Ascites
iii. Cirrhosis
iv. Wernicke-Korsakoff
v. Malnutrition
k. Seizures are usually a result of withdrawal (within 2448 hours of last drink), not intoxication
i. Give them benzodiazepines
l. Lab/Physical Exam

i.

11.

12.

m.Treatment
i. Fluids
ii. Thiamine
iii. Dextrose
iv. PO4
v. Magnesium
vi. Correction of acidosis
Drug intoxication (intentional or unintentional)
a. CNS stimulants
i. Amphetamine, cocaine
ii. HTN, tachycardia, pupil dilatation
b. CNS depressants
i. Benzodiazepines, opioids, barbiturate
ii. History of use/overdose
iii. Exposure
iv. Needle marks
v. Respiratory depression
vi. Dizziness
vii. Stupor
c. CO, CN, Methlene, Lead
d. EtOH
e. Diagnosis depends on drug/toxin levels
f. Treatment
i. Supportive
ii. Naloxone
iii. Flumazenil
Acute/Chronic Renal Failure
a. Swelling
b. SOB
c. Polyuria

d. HTN Hypotension
e. Risk Factors
i. Uncontrolled HTN
ii. Uncontrolled DM
f. Complications (Uremia)
i. Uremic gastritis N/V
ii. Uremic pericarditis SOB, pleuritic chest pain
iii. Uremic encephalopathy dizziness, confusion,
coma
iv. Hyperkalemia arrhythmias palpitations
1.

v. Hypocalcemia secondary hyperparathyroidism

bone pain, fractures
vi. Metabolic acidosis SOB, coma
g. Labs/Physical Exam
i. Creatinine
ii. BUN
iii. CMP
iv. Urinalysis

1.

a. Pre-renal = everything high, fractional

excretion of sodium low
b. Renal = everything low, bodys not trying
to retain fluid at all, FENA is high

13.

h. Treatment
i. Treat underlying cause
ii. Dialysis
iii. Indications for dialysis = metabolic acidosis,
hyperkalemia, uremia
Chronic Liver Failure
a. LE Swelling
b. Abdominal Swelling
c. SOB
d. Risk Factors:
i. Viral Hepatitis (alcohol + Hep C the biggest causes
in the USA)
ii. Drug induced hepatitis
iii. Autoimmune hepatitis
iv. PBC
e. Cirrhosis Portal HTN Varices
i. Varices lead to Upper & Lower GI Bleed,
hematemesis or melena
f. Complications
i. Encephalopathy
1. Any bleeding
2. Infection
3. Drugs (NSAIDS, acetaminophen,
benzodiazepine, alcohol)
4. Elevated Ammonia
ii. Ascites spontaneous bacterial peritonitis
iii. Hypoproteinemia edema + Vitamin deficiency

14.

15.

16.

iv. Clotting factor deficiency INR bleeding

v. Thrombocytopenia bleed
vi. Gynecomastia
vii. Spider angiomas
viii. Caput medusae
ix. Jaundice
g. Lab/Physical Exam
i. LFTs
ii. Creatinine
iii. BUN
iv. CMP
v. Peritoneal tap for spontaneous bacterial peritonitis
1. Infection = exudate
2. No infection = transudate
h. Treatment
i. Diuretics to control portal pressure
ii. Liver transplant depending on MELD score/Child
Score (Bili, INR, Creatinine)
i. Hemorrhage/Encephalopathy = hypovolemic shock
coma
Gastroenteritis
a. Dehydration vomiting Hypovolemia Shock
Coma
b. History of GE
c. Decreased skin turgor
d. Low BP
e. Increased HR
f. Decreased urine output renal failure
g. Lack of tears
h. Somnolence
i. Lab/Physical Exam
i. UA = specific gravity high, urine osmolality high
ii. FENA = low
iii. BUN/CR = high
j. Treatment
i. IV fluids
ii. Supportive
Septic shock
a. Untreated focused infection
b. Systemic infection pro-inflammatory proteins
widespread tissue injury vasodilation
i. Vasodilation Reduced SVR
ii. Reduced SVR Hypotension/Tahcycardia
iii. Hypotension/Tachycardia Septic shock
DIC
a. Causes

i. Sepsis
ii. Malignancy
iii. Trauma
iv. Obstetrical conditions
v. Intravascular hemolysis (transfusion reaction)
b. Pathophysiology

i. Underlying condition leads to activation of

intravascular coagulation and endothelial damage
ii. Increased intravascular coagulation leads to:
1. Decreased platelets
2. Decreased coagulation factors (increased PT
and aPTT)
3. Fibrin deposition (increased D-dimer and
FDPs)
iii. Impaired coagulation leads to bleeding
iv. Increased fibrin and endothelial damage leads to
thrombosis and organ ischemia
c. Bleeding
d. Skin changes
e. End organ damage due to thrombosis and ischemia
f. Hypovolemia Coma
g. Complications
i. Renal failure
ii. Shock
iii. Hepatic Failure
iv. Coma