nh gi cp cu bnh nhn c

ri lon thc v hn m
Evaluating ED Patients Who Present with AMS & Coma

Systematic Approach
TS. CAO PHI PHONG

Cc cu hi t ra

How to evaluate this unresponsive pt?

What is the differential diagnoses?
What are the etiologies of coma?
What tests must be performed?
What neuroimaging to be obtained?
What therapies must be provided?
TS. CAO PHI PHONG

NH NGHA V CHN
ON PHN BIT HN M
AMS & Coma: Key Concepts

TS. CAO PHI PHONG

Definition of Coma
Glasgow coma score of less than 10
Eyes closed unresponsiveness
@ Eye opening 1-4
@ Verbal 1-5
@ Motor 1-6

TS. CAO PHI PHONG

After ABCs stabilized. . .

Quickly investigate cause
DERM

TS. CAO PHI PHONG

The
The RAS
RAS and
and Essential
Essential Neurotransmitters
Neurotransmitters

Epinephrine:
Locus Coeruleus
Serotonin:
Median Raphe
Acetylcholine:
Basal Nucleus

TS. CAO PHI PHONG

Coma Pathophysiology
Bilateral cerebral cortex dysfunction
Toxic/metabolic
Mass lesion, increased ICP
Cerebral ischemia, infarct

Brainstem suppression of reticular

activating system (RAS)
Ischemia, infarct
TS. CAO PHI PHONG

Stupor & Lethargy

Stupor definition:
A state of reduced or suspended
sensibility, a daze
(cam giac bi inh chi hay sng s)
Decreased responsiveness
Similar to lethargy

Reduced GCS, but above 8

TS. CAO PHI PHONG

Acute Delirium
Delirium definition:
Mental confusion
Clouded consciousness
Disorientation, hallucinations
Delusions, anxiety (ao giac, lo u)
Incoherent speech (li noi khng mach lac)

GCS generally above 8

TS. CAO PHI PHONG

Coma
Coma definition:
Extreme alteration in mental status
Unresponsive
Similar to being unconscious

Markedly low GCS, 8 or less

TS. CAO PHI PHONG

(1) Coma, stupor, lethargy

(a)Description * Depressed level of alertness *
For facilitating communication & enhancing
consistency
(b) Example * 'Patient was stuporous': provide
little information * 'Mr.Z lay motionless in
bed unless called loudly by name, when he
opened his eye briefly and looked to the
left. He failed to answer any questions or to
follow instructions' (chi thi)
TS. CAO PHI PHONG

(2) Behavioral states confused with coma

1. Locked-in syndrome
2. Persistent vegetative state
3. Abulia (akinetic mutism )
4. Catatonia
5. Pseudocoma
TS. CAO PHI PHONG

Akinetic mutism
(a)Characteristics * State that seemingly awake, but
remains silent & motionless * Only eye dart in direction
of moving object * Despite lack of movement, few
motor signs or movement (mt nhin theo muc tiu
chuyn ng)
- Frontal release sign (sucking, grasp reflex: px bu,
cm nm)
- Move one side or one arm in stereotyped fashion
-Pyramidal sign in paralyzed limb
TS. CAO PHI PHONG

(b) Lesion
- Bilateral frontal lesion (anterior cingulate gyrus)
- Diencephalic-mesencephalic reticular formation
- Globus pallidus or hypothalamus
- Common etiology --Anoxia, head trauma,
cerebral infarction, severe acute hydrocaphalus,

TS. CAO PHI PHONG

(c) Differnetial diagnosis

Psychogenic (often catatonic) unresponsiveness
- Unless available history, may be difficult to distinguish
- Signs favoring akinetic mutism: frontal release sign,
pyramidal sign: slow-wave abnormality in EEG
- Signs favoring catatonia: normal EEG (often
desynchronized low-voltage fast activity)

TS. CAO PHI PHONG

Persistent vegetative state (PVS)

Definition: vegetative state present 1 month after
acute traumatic or nontraumatic brain injury
- vegetative state lasting for at least 1 month in
degenerative, metabolic, developmental
malformation

TS. CAO PHI PHONG

Features:
-

lack of awareness of self & external stimuli

accompanied by sleep-wake cycle (con chu ky ngay m)
preservation of vital vegetative function
no evidence of sustained, reproducible, purposeful,
voluntary behavior.
no evidence of language comprehension or expression
bowel & bladder incontinence
variably preserved cranial nerve & spinal reflexes
Lesion:
severe or widespread cerebral hemispheric
(Sinh san)

TS. CAO PHI PHONG

Locked-in syndrome
(a)Features
Mute, motionless
-

But, remain awake, alert, aware of self, capable of

perceiving sensory stimuli

Impaired horizontal eye movement (d/t involvement of

PPRF in pontine lesion)

Intact vertical eye movement or eyelid movement

(capable of response to command)
TS. CAO PHI PHONG

(b) Lesion
- Pontine lesion
- Basilar artery thrombosis /c ventral pontine infarct,
Pontine hemorrhage, pontine tumor.
- Central pontine myelinolysis
- Midbrain lesion (bilateral ventral region):
(Bilateral ptosis & vertical, horizontal ophthalmoplegia)

- Bilateral internal capsular lesion

- Tentorial herniation, GBS, MG
TS. CAO PHI PHONG

CN NGUYN HN M

TS. CAO PHI PHONG

Coma Etiologies
Hypoperfusion/ischemia
Toxic/metabolic
Increased ICP
Chronic space-occupying lesion
Acute hemorrhage

Infection
Seizure
Psychogenic fugue state

TS. CAO PHI PHONG

Coma Etiologies
AEOIU-TIPS

TS. CAO PHI PHONG

Coma Etiologies

T trauma, temperature
I infections
P psychiatric, porphyria
S space-occupying lesion,
stroke, SAH

TS. CAO PHI PHONG

Coma Etiologies

A
E
I
O
U

alcohol, other toxins

endocrine
insulin (DM complications)
oxygen deficiency, opiates
uremia, renal disorders

TS. CAO PHI PHONG

NH GI BN HN M

TS. CAO PHI PHONG

nh gi bnh nhn hn m
Assess ABCs, vitals
Provide empiric therapies
Assess for signs of likely etiology
Trauma, toxic, infection, ischemia, tumor

Conduct a systematic neurological exam

Obtain neuroimaging
Consider EEG monitoring
TS. CAO PHI PHONG

CC THANG IM NH GI BNH NHN

HN M

TS. CAO PHI PHONG

LEVEL OF CONSCIOUSNESS

TS. CAO PHI PHONG

Coma Scales
Glasgow Coma Scale (GCS),
ACDU (alert, confused, drowsy, unresponsive)
AVPU (alert, response to voice, response to pain,
unresponsive)

FOUR scale (full outline of unresponsiveness),

TS. CAO PHI PHONG

AVPU

TS. CAO PHI PHONG

 AVPU are about as accurate as the

GCS and much easier to use.
ACDU scale appears better at
identifying early deterioration in
level of consciousness

TS. CAO PHI PHONG

A recently validated coma scale, the

FOUR scale (full outline of
unresponsiveness), provides more
neurologic detail than the GCS

TS. CAO PHI PHONG

TS. CAO PHI PHONG

FOUR Score

Why a New Coma Scale?

Glasgow Coma scale (GCS)

Widely adopted
Fairly simple
Good inter rater reliability
Sensible
The lower the number the worse the
condition
TS. CAO PHI PHONG

FOUR Score

Why a New Coma Scale? GCS shortcomings

Glasgow Coma scale (GCS)

Fails to assess the verbal score in intubated
patients
1/3 of scale lost in these patients

Does not test brain stem reflexes

Does not detect subtle changes in
neurological examination
Lack of correlation between outcome and
GCS in head trauma patients
TS. CAO PHI PHONG

FOUR Score
Research Protocol

Aims:
1. To evaluate the use of the FOUR score
in the prehospital setting
2. To test agreement between emergency
care providers when measuring the
FOUR score
TS. CAO PHI PHONG

FOUR Score

Research Protocol-Outline
TransportingtoAGMC
EMSpatientwithGCS14
Any
etiology

Pre
H

osp
ita

PERFORMEMSFOURScore
PerformE.D.FOURScore

E.D
.

PerformI.C.U.FOURScore

IC
U

At24hours

Outcomeat30days

TS. CAO PHI PHONG

FOUR Score

Why a New Coma Scale? Need better assessment tool!

Has 4 testable components

Eyes
Motor
Breathing
Respirations

Maximum score for each is 4

GCS varies E-4, V-5, M-6
TS. CAO PHI PHONG

FOUR Score

Examination of the Eyes

4 - eyelids open; tracking or blinking to

command
3 - eyelids open; not tracking
2 eyelids closed;
open to loud sound (voice or hand clap)

1 eyelids closed; open to pain

0 eyelids closed even with painful stimuli
TS. CAO PHI PHONG

FOUR Score

Examination of the Eyes-Picture

TS. CAO PHI PHONG

FOUR Score

Examination of the Eyes-Additonal Instructions

Grade the best possible response after at least 3

trials in an attempt to elicit the best level of
alertness.
If eye lids are closed, the examiner should open
them and examine tracking of finger or object.
Tracking with the opening of one eyelid will
suffice(p ng) in cases of eyelid edema or
facial trauma.
TS. CAO PHI PHONG

FOUR Score
Motor Examination

4 thumbs up, peace sign(a 2 ngn

tay nh ch V), or fist sign(nm cht) to
command
3 localizing to pain
2 flexion response to pain
1 extensor response
0 no response to pain or generalized
myoclonus status
TS. CAO PHI PHONG

FOUR Score

Motor Examination-Additional Instructions

Grade the best possible response

using the UPPER extremities
Painful stimulus can be elicited over:
TEMPOROMANDIBULAR JOINT or
SUPRAORBITAL NERVE

TS. CAO PHI PHONG

FOUR Score

Brainstem Examination

4 normal pupil and corneal reflexes

3 one pupil wide and fixed
2 absent pupil or corneal reflex
1 absent pupil reflex, absent
corneal reflex
0 absent pupil reflex, absent
corneal reflex, absent cough reflex
TS. CAO PHI PHONG

FOUR Score

Brainstem Examination- Picture

TS. CAO PHI PHONG

FOUR Score

Brainstem Examination-Additional Instructions

Examines pupillary and corneal reflexes.

Preferably, corneal reflexes are tested by instilling 2-3
drops of sterile saline on the cornea from a distance of 46 inches
this minimizes corneal trauma from repeated examinations).

THE STERILE SALINE USED FOR NEBULIZER TREATMENTS IS

AN EXCELLENT CHOICE
Sterile cotton swabs can also be used.

The cough reflex is tested ONLY WHEN BOTH OF THESE

REFLEXES ARE ABSENT
Usually tracheal suctioning is performed

Jiggle the ETT [in/out] to attempt to elicit a cough

response
TS. CAO PHI PHONG

FOUR Score

Examination of Breathing

4 regular breathing pattern

3 Cheynes-Stokes breathing pattern
2 irregular breathing pattern
1 triggers ventilator
0 apnea

TS. CAO PHI PHONG

FOUR Score

Examination of Breathing-Picture

TS. CAO PHI PHONG

FOUR Score

Examination of Breathing-Additional Instructions

2 type of patients
Intubated or NOT intubated
YOU ARE THE VENTILATOR

R = 4 & R = 2 are for NON-INTUBATED PATIENTS

Cheyne-Stokes breathing is a regularly irregular
pattern of breathing characterized by periods of
breathing with gradually increasing and decreasing
tidal volume interspersed with periods of apnea. (can
be intubated)
Cheyne-Stokes breathing is given a score of R = 3
Must observe VERY closely!

TS. CAO PHI PHONG

FOUR Score

Examination of Breathing-Additional Instructions

In patients being BAGGED, the pressure

waveforms from a ventilator are not
available! Any spontaneous respiratory
pattern/effort that the patient makes is
given a score of R = 1
If the patient is not making ANY
respiratory effort, a score of R = 0, is
given.
TS. CAO PHI PHONG

FOUR Score

Motor Examination-Picture

TS. CAO PHI PHONG

(Theo di)

(Bn tay nm cht hay yn lng)

TS. CAO PHI PHONG

NG T

TS. CAO PHI PHONG

PUPILLARY RESPONSES

TS. CAO PHI PHONG

Px nh sng
Px hi t v iu tit

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

The anatomical basis of

convergence and
accommodation.
b The ciliary muscle in
relaxation (vision at a
distance).
c The ciliary muscle in
contraction (near vision

TS. CAO PHI PHONG

TS. CAO PHI PHONG

1. Afferent input: optic nerve, optic chiasm, optic tract,

and projections into the midbrain tectum
2. Efferent fibers: the Edinger-Westphal nucleus and
oculomotor nerve.
3. Abnormalities in pupil size and reactivity
- structural damage between the thalamus and pons,
- warning sign brainstem herniation,
- differentiate structural causes of coma from
metabolic causes.
TS. CAO PHI PHONG

1. Thalamic lesions: small, reactive pupils: diencephalic

pupils. (toxic-metabolic)
2. Hypothalamic lesions: or lesions elsewhere along
the sympathetic pathway: Horner's syndrome
3. Midbrain lesions: three types of pupillary
abnormality, depending on where the lesion occurs
- Dorsal tectal lesions: midposition eyes, fixed to
light but react to accommodation, (impossible to test
in the comatose patient)

TS. CAO PHI PHONG

4. Nuclear midbrain lesions: affect both sympathetic

and parasympathetic pathways: fixed, irregular
midposition pupils
5. Lesions of the third nerve: wide pupillary dilation,
unresponsive to light
6. Pontine lesions: interrupt sympathetic pathways:
small, pinpoint pupils, remain reactive.
7. Lesions above the thalamus and below the pons:
pupillary function intact, except for Horner's
syndrome in medullary or cervical spinal cord
lesions.
TS. CAO PHI PHONG

- Asymmetry in pupillary size or reactivity, even of

minor degree, is important
- Asymmetry of pupil size may be due to dilation
(mydriasis) of one pupil, third nerve palsy, or
contraction (miosis) of the other, Horner's syndrome
- A sluggishly reactive pupil may be one of the first
signs of uncal herniation

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

Hippus
Hippus, also known as pupillary athetosis, is spasmodic,
rhythmic (< 0.04 Hz), but irregular dilating and contracting
pupillary movements between the sphincter and dilator
muscles. Pupillary hippus comes from the Greek hippos
meaning horse, perhaps due to the rhythm of the
contractions representing a galloping horse.
It is particularly noticeable when pupil function is tested
with a light, but is independent of eye movements or
changes in illumination. It is usually normal, however
pathological hippus can occur.
Hippus has been classically been noted as sign of Aconite
poisoning (ng c cy phu t)
TS. CAO PHI PHONG

 hippus /hippus/ (hipus) abnormal

exaggeration of the rhythmic contraction
and dilation of the pupil, independent of
changes in illumination or in fixation of the
eyes(chiu sng hay c inh mt).

TS. CAO PHI PHONG

1. Px ng t p ng i xng 2 bn no gia bnh thng

2. Normal pupils + Absent Dolls Metabolic / Sedatives
3. Fixed Mid position pupil Focal Midbrain Lesion
4. Pinpoint Reactive Pontine Damage / Opiate /
Hydrocephalus / Thalamic Hemorrhage
5. Unil / Dil / Fixed Uncal Herniation - same/opposite
6. Bil / Dil / Fixed Central Herniation / Hypoxia / Atropine or
Barbiturate Poisoning / Mydriatics
7. Bu duc khng ng tm - Early midbrain/III n. Compression
8. Unil / Small (Horner) Large Cerebral Hemorrhage Affecting
Thalamus

TS. CAO PHI PHONG

OCULOMOTOR RESPONSES
RESTING AND SPONTANEOUS EYE MOVEMENTS

Conjugate lateral deviation of the eyes

Conjugate vertical deviation of the eyes
Nonconjugate eye deviation
Skew deviation
Roving eye movements
Nystagmus
Ocular bobbing and dipping
TS. CAO PHI PHONG

Ocular Motility
Cerebrum, cerebellum, and brainstem
Evaluation of ocular motility:
(1) observation of the resting position of the
eyes, including eye deviation;
(2) notation of spontaneous eye movements.
(3) testing of reflex ocular movements
TS. CAO PHI PHONG

CONJUGATE LATERAL DEVIATION OF THE EYES

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

1. Conjugate lateral eye deviation

@ ipsilateral lesion
@ contralateral lesion
2. Downward deviation of the eyes
@ Brainstem lesions (most often from tectal compression) ,
hepatic coma.
@ Thalamic and subthalamic lesions: downward and inward
3. upward eye deviation
@ Sleep, seizure, syncope, Cheyne-Stokes, hemorrhage
vermis, brainstem ischemia or encephalitis
TS. CAO PHI PHONG

4. Skew deviation
@ posterior fossa lesion (brainstem or
cerebellar)
@ Dysconjugate vertical eye position may
sometimes occur in the absence of a
brainstem lesion in the obtunded patient.
TS. CAO PHI PHONG

Skew deviation is a pure vertical ocular deviation

that is not due to a cranial nerve palsy, orbital lesion,
or strabismus but to disturbed supranuclear input to
the third and fourth cranial nerve nuclei. It is thought
to be due to unilateral damage to the otolith-ocular
pathways or the pathways mediating the VOR.

TS. CAO PHI PHONG

Spontaneous eye movements.

1. Roving eye movements
- slow, conjugate, lateral to-and-fro
- brainstem is intact
- metabolic or toxic cause or bilateral
lesions above the brainstem ( may be ocular
palsies or internuclear ophthalmoplegia )
TS. CAO PHI PHONG

Spontaneous eye movements.

2. Nystagmus (irritative or epileptogenic
supratentorial focus)
- Manifestations of seizures (eye, eyelid, face,
jaw, or tongue )
- EEG

TS. CAO PHI PHONG

Spontaneous eye movements.

3. Spontaneous conjugate vertical eye
movements
- Ocular bobbing: rapid downward jerks of
both eyes, followed by a slow return to the
midposition.
- Typycal form : paralysis of both reflex and
spontaneous horizontal eye movements.)
TS. CAO PHI PHONG

Spontaneous eye movements.

3. Spontaneous conjugate vertical eye
movements
- Reverse bobbing : Fast up; slow downward
return to primary position
@ nonlocalizing, encephalopathy

TS. CAO PHI PHONG

Spontaneous eye movements.

3. Spontaneous conjugate vertical eye
movements
- Ocular dipping (inverse ocular bobbing):
initial slow downward phase is followed by a
relatively rapid return (diffuse cerebral
damage)

TS. CAO PHI PHONG

Spontaneous eye movements.

4. Vertical nystagmus: abnormal pursuit or
vestibular system (slow deviation of the eyes from
the primary position, with a rapid, immediate
return to the primary position )
@Ocular-palatal myoclonus: damage to the lower
brainstem (Guillain-Mollaret triangle , cerebellar
dentate, red nucleus, and inferior olive)
@Ocular flutter: back-to-back saccades horizontal
TS. CAO PHI PHONG

5. Tam gic Mollaret l g?

TS. CAO PHI PHONG

 Mollaret's triangle:
gia red nucleus, inferior olives,
v dentate nucleus tiu no. Tn
thng gy palatal myoclonus

TS. CAO PHI PHONG

Tn thng Inferior Olivary Nucleus:

Oculopalatal Tremor (myoclonus)
(git c nhn cu-khu cai)

TS. CAO PHI PHONG

Vn ng mt bt thng trong tn thng

Inferior Olivary Nucleus: Oculopalatal Tremor

Vertical pendular nystagmus

Vn ng ng b ca hu, mt, c cng
mng nh, dy thanh, vai v c h hp.
(Synchronous rhythmic movements of the
pharynx, face, tensor tympani, vocal cords,
shoulders, and respiratory muscles)
TS. CAO PHI PHONG

Cn nguyn Oculopalatal Tremor

Infarct
Hemorrhage
Demyelination (rare)

TS. CAO PHI PHONG

PHAN XA VN NG MT
(Reflex Ocular Movements)

TS. CAO PHI PHONG

@oculocephalic reflex (doll's eye

phenomenon)
@ vestibulo-oculogyric reflex, by caloric
(thermal) testing.
doll's eye phenomenon and doll's eye
maneuver = oculocephalic reflex,
COWS (cold opposite, warm same) fast phases
TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

 Stimulate right anterior canal (RAC): both eyes

rotate up and counterclockwise (from patient's
point of view
Stimulate left anterior canal (LAC): both eyes
rotate up and clockwise
Stimulate right posterior canal (RPC): both
eyes rotate down and counterclockwise
Stimulate left posterior canal (LPC): both eyes
rotate down and clockwise
TS. CAO PHI PHONG

RESPIRATION
Neuropathologic Correlates of Breathing
Abnormalities

TS. CAO PHI PHONG

Forebrain damage
Epileptic respiratory inhibition
Apraxia for deep breathing or breath
holding
Pseudobulbar laughing or crying
Posthyperventilation apnea
Cheyne-Stokes respiration
TS. CAO PHI PHONG

Hypothalamic-midbrain damage
Central reex hyperpnea
(neurogenic pulmonary edema)

TS. CAO PHI PHONG

Basis pontis damage

Pseudobulbar paralysis of voluntary
control

TS. CAO PHI PHONG

Lower pontine tegmentum damage

or dysfunction
Apneustic breathing
Cluster breathing
Short-cycle anoxic-hypercapnic
periodic respiration
Ataxic breathing (Biot)
TS. CAO PHI PHONG

Medullary dysfunction
Ataxic breathing
Slow regular breathing
Loss of autonomic breathing with
preserved voluntary control
Gasping

TS. CAO PHI PHONG

TS. CAO PHI PHONG

Apneusis: inspiratory
pauses, may be seen in
patients with bilateral
pontine lesions.
Cluster breathing and
ataxic breathing: lesions
at the pontomedullary
junction
Apnea
TS. CAO PHI PHONG

NH GI VN NG

TS. CAO PHI PHONG

MOTOR RESPONSES
Patients with forebrain or diencephalic
lesions often have a hemiparesis
Lesions involving the junction of the
diencephalon and the midbrain may
show decorticate posturing, including
exion of the upper extremities and
extension of the lower extremities
TS. CAO PHI PHONG

MOTOR RESPONSES
Lesion progresses into the
midbrain, there is generally a shift to
decerebrate posturing

TS. CAO PHI PHONG

Mt v v mt no
(Decorticate vs. Decerebrate)

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

TS. CAO PHI PHONG

Major Descending Spinal Tracts

Motor Cortex

Lateral

Red
Nucleus

Ventromedial

Reticular
Nuclei

Superior Colliculus
vestibular nuclei

Spinal cord
TS. CAO PHI PHONG

(--)

HE
THAP

Nhan
o

Gia c kh nng
chng trng lc
(--)

C gap chi
tren
Bo tien
nh song

C duoi
t ch

Bo li
song

Gia c trng lc
dui
TS. CAO PHI PHONG

Decorticate vs. Decerebrate

A UMN lesion above the level of the red nucleus will

result in decorticate posture
(thumb tucked under flexed fingers in fisted position,
pronation of forearm, flexion at elbow with the lower
extremity in extension with foot inversion)

Lesion below the level of the red nucleus but above the
level of the vestibulospinal and reticulospinal nuclei will
result in decerebrate posture
(upper extremity in pronation and extension and the
lower extremity in extension).

TS. CAO PHI PHONG

- red nucleus output reinforces antigravity flexion of the upper

extremity (gia c khng trong lc gp 2 chi trn).
- when its output is eliminated then the unregulated reticulospinal
and vestibulospinal tracts reinforce extension tone of both upper
and lower extremities.
- lesion in the medulla: all the brainstem motor nuclei as well as the
direct corticospinal tract would be out: patient would be flaccid
acutely.
- If the patient were to survive, tone would return because of
interneuronal activity at the spinal cord level.
TS. CAO PHI PHONG

TS. CAO PHI PHONG

Empiric Therapies:
The Procedure
TS. CAO PHI PHONG

Empiric Therapies: Principles

Airway management:
Nasal or oral airway, ventilate, prepare for RSI

Oxygen therapy
Obtain an accucheck, administer glucose
Fluid bolus for hypotension
Naloxone if evidence of narcotic use/abuse
Judicious flumazenil use for benzo abuse
Thiamine in alcohol abuse

La chn

TS. CAO PHI PHONG

Empiric Therapy
Control the airway, ventilate

TS. CAO PHI PHONG

Empiric Therapy
Control the airway, ventilate
Do a bedside glucose determination
Provide D50 for hypoglycemia
Avoid hyperglycemia

TS. CAO PHI PHONG

Empiric Therapy
Control the airway, ventilate
Do a bedside glucose determination
Provide D50 for hypoglycemia
Avoid hyperglycemia

Detect hypoperfusion (Decreased CPP)

CPP = MAP ICP (MAP > 90 mmHg key)
NS fluid boluses up to 500 cc each
TS. CAO PHI PHONG

Empiric Therapy
Assess for narcotic overdose
Nalaxone 2 mg IV or sublingual
Be prepared to restrain patient

TS. CAO PHI PHONG

Empiric Therapy
Assess for narcotic overdose
Nalaxone 2 mg IV or sublingual
Be prepared to restrain patient

Assess for benzodiazepine overdose

Flumazenil 0.2 mg IVP x 5 (max dose 1 mg)
If acute ingestion, initial dose OK, no
seizure
TS. CAO PHI PHONG

Empiric Therapy
Assess for narcotic overdose
Nalaxone 2 mg IV or sublingual
Be prepared to restrain patient

Assess for benzodiazepine overdose

Flumazenil 0.2 mg IVP x 5 (max dose 1 mg)
If acute ingestion, initial dose OK, no seizure

Examine for likely EtOH abuse

Thiamine 100 mg IVP or to IVF
TS. CAO PHI PHONG

Coma Patient Evaluation:

The Procedure
TS. CAO PHI PHONG

Coma Exam: Principles

Many etiologies are apparent on exam

Step-wise approach allows for detection
Follows empiric therapies
Precedes, directs neuroimaging
Establishes baseline
Mental status change then detectable

R rang

TS. CAO PHI PHONG

Coma Evaluation Procedure

Assess the pts overall mental status

TS. CAO PHI PHONG

Coma Evaluation Procedure

Assess the pts overall mental status
Assess the ABCs (trauma)
Airway & gag reflex
Breathing pattern and sufficiency
Circulation adequacy and hypotension

TS. CAO PHI PHONG

Coma Evaluation Procedure

Assess the pts overall mental status
Assess the ABCs (trauma)
Airway & gag reflex
Breathing pattern and sufficiency
Circulation adequacy and hypotension

Assess the skin, breath (toxidromes)

TS. CAO PHI PHONG

Coma Evaluation Procedure

Assess the pts overall mental status
Assess the ABCs
Airway & gag reflex
Breathing pattern and sufficiency
Circulation adequacy and hypotension

Assess the skin, breath (toxidromes)

Detect posturing following stimulation
TS. CAO PHI PHONG

Decorticate posturing in comatose patient

Lesion above the red nucleus
Lower limbs extend, upper limbs flex following stimulus
Activity in the brainstem flexor center, the red nucleus

TS. CAO PHI PHONG

Decerebrate posturing in comatose patient

Upper and lower limbs extend following stimulus
(pain, startle,or auditory)
Normal inhibition by cortex on the extensor facilitation part of
ret form is missing, so extensors hyperactive
Lat vest nuclei involved, ablate and extensor posturing reduced

TS. CAO PHI PHONG

Clinical Value of Decorticate/Decerebrate Signs

Decorticate posturing indicates a higher level of brainstem
injury than decerebrate posturing (a good thing), so
Comatose patients who go from decerebrate to decorticate
(ascending progression of impaired area) have
a better prognosis than those that go from decorticate to
decerebrate (descending progression of impaired area).
Descending impairment will be fatal if medullary respiratory
and cardiovascular centers are damaged

TS. CAO PHI PHONG

Coma Evaluation Procedure

Calculate the Glasgow Coma Scale score
Eye Opening (4), Verbal (5), Motor (6)
13-15 Mild AMS, 4-8 Coma, 3 Vegetative

TS. CAO PHI PHONG

Coma Evaluation Procedure

Calculate the Glasgow Coma Scale score
Eye Opening (4), Verbal (5), Motor (6)
13-15 Mild AMS, 4-8 Coma, 3 Vegetative

Detect abnormal reflexes

Corneal reflex
Babinski (Chadduck)
TS. CAO PHI PHONG

Coma Evaluation Procedure

Examine the pupils
Size and equality
Light reactivity, consensual response

TS. CAO PHI PHONG

Coma Evaluation Procedure

Examine the pupils
Size and equality
Light reactivity, consensual response

Perform the Dolls eye maneuver

TS. CAO PHI PHONG

Dolls Eye Maneuver

Oculocephalic reflex
Caution with suspected c-spine injury
Eyes should continue to face to ceiling
If eyes follow movement of head to side,
suspect brainstem involvement in coma

TS. CAO PHI PHONG

Coma Evaluation Procedure

Examine the pupils
Equality
Light reactivity

Perform the Dolls eye maneuver

Detect evidence of psychogenic coma
Protective reflex
Propriety reflex
TS. CAO PHI PHONG

Coma Evaluation Procedure

Look for ongoing seizure activity

TS. CAO PHI PHONG

Coma Evaluation Procedure

Look for ongoing seizure activity
Perform cold calorics

TS. CAO PHI PHONG

Cold Caloric Examination

Oculovestibular reflex
Normal for slow movement of eyes
towards, fast movement away from cold
water into ear canal
If eyes move towards cold water, intact
brainstem despite coma
If no eye movement towards stimulation,
suspect brainstem injury
TS. CAO PHI PHONG

Coma Evaluation Procedure

Look for ongoing seizure activity
Perform cold calorics
Document checklist of coma findings
Presence of coma, responsiveness, GCS
Vital signs, ABCs, empiric therapies
Exam findings checklist
Likely etiology
Likely location of lesion
TS. CAO PHI PHONG

ED Documentation &
Patient Outcome

TS. CAO PHI PHONG

ED Coma Documentation
Pt unresponsive to all stimuli cw coma
Airway adequately controlled
Decreased gag reflex
OK Airway with nasopharyngeal airway

Adequate ventilation, pO2 OK 100% NRB

Hypertension noted, tachycardia
Labetalol 20 mg IVP
Repeat BP OK
Consistent/with

TS. CAO PHI PHONG

ED Coma Documentation
No pallor, cyanosis, or cherry red skin
No abnormal breath or EtOH
Adequate ventilation, pO2 OK 100% NRB
Hypertension noted, tachycardia
Labetalol 20 mg IVP
Repeat BP OK

No pathologic posturing to stimulation

Estimated GCS = 3
TS. CAO PHI PHONG

ED Coma Documentation
Corneal reflex intact, no upgoing toes bilat
Pupils midrange, equal, reactive
Fixed gaze to R, no Dolls eyes noted
Protective reflex to arm dropping absent
No propriety reflex noted
Facial twitching noted on R, likely SE
Cold calorics not indicated
TS. CAO PHI PHONG

ED Coma Documentation
Coma
Likely etiology subtle status epilepticus
No toxidrome or intoxication
Non-focal exam, mass lesion not likely
No evidence psychogenic seizure
CT negative, tox screen negative
Lorazepam, fosphenytoin
EEG negative in ED
TS. CAO PHI PHONG

Patient Outcome
Hx SE, compliant with meds?
Hx carotid occlusion
Due to have carotid endarterectomy
Pt remained unresponsive after EEG
Admitted for ongoing observation
Expedited surgery anticipated
TS. CAO PHI PHONG

ED Comatose Patient Exam:

A Retrospective

TS. CAO PHI PHONG

ED Comatose Patient Exam

Address the ABCs

Quickly assess for coma etiologies
Perform a systematic neuro exam
Expedited neuroimaging, consultation
Documentation of coma checklist
Definitive care plan established in ED
Optimized coma patient outcome
TS. CAO PHI PHONG

Questions??

TS. CAO PHI PHONG