1. The Comatose Patient Hans House, MD, FACEP Professor Department of Emergency Medicine University of Iowa

2. Objective  Outline the general approach to the patient with stupor or coma, including the use of clinical, laboratory, and imaging investigations

3. Pathophysology

4. Initial Management  A: Airway control if needed  B: Assist ventilations, 100% O 2  C: Volume if hypotensive  D: Dextrose  Consider: glucose, thiamine, nalaxone

5. Differential Diagnosis  A - alcohol, anoxia  E - epilepsy  I - insulin (diabetes)  O - overdose  U - uremia, underdose  T- trauma  I - infection  P - psychiatric  S – stroke / sub-arachnoid

6. Differential Diagnosis Most common ED diagnosis:  Trauma  CVA  Intoxications  Metabolic  Post- ictal state  Post- cardiopulmonary arrest

7. Differential Diagnosis 1) Cerebral Anemia 2) Mechanical injury 3) Convulsive attacks 4) CVA 5) Poisons, endogenous and exogenous 6) Infection Young GS. Can Med Assoc J. 1934; 31(4): 381–385.

8. General Approach: History “Further history limited to patient’s medical condition”

9. General Approach: History Ask family, EMS, chart:  Time course of onset  Duration of symptoms  Focal signs  Past Medical History  Medications  Alcohol or drug use

10. General Approach: Physical  PE normal in 85% of all patients  Vital signs are vital!  Elevated or lowered temp may be helpful  Need a core temp!  Ventilatory patterns not helpful

11. General Approach: Physical  After nervous, skin is the most useful system to examine  Trauma  Infection  Toxidromes  Jaundice  Seizure trauma  Rhinnorrhea

12. General Approach: Physical  Nervous System  Assess and document level of arousal  Useful for prognosis, not diagnosis  Use GCS  “Less than eight, in-tu-bate!”

13. General Approach: Physical  Assessing level of arousal  Shouting, sternal rub, pinching trapezius, nailbed pressure  Supraorbital pressure? Smelling Salts?

14. General Approach: Physical  Motor function  Unable to do routine oppositional force  Use reflexes  Look for asymmerty

15. General Approach: physical Cranial nerves: Pupils  Supertentorial mass/ hemorrhage or primary brainstem lesion  Disruption of 3 rd CN or brainstem nuclei  Transtentorial herniation:  First dilation/ loss of light reflex  Later, midrange (4-5mm) and fixed  May be mimicked in severe sedative O/D

16. General Approach: physical Cranial nerves: Pupils  20% of population have 1mm difference in pupil size  Try looking at Driver’s License for previous doc. of anisicoria  Huge: anticholinergic  Tiny: pontine, opiate

17. General Approach: Physical Cranial Nerves: eye movements  Large cerebral mass lesions cause deviation toward side of lesion  Seizure focus (irritable inflammation or blood) causes deviation away from lesion  Vestibuloocular reflexes  Oculocephalic (doll’s eyes)  Oculovestibular (caloric testing)

18. General Approach: Physical Oculocephalic Reflex  Normal is for the eyes to turn opposite to head movement to keep focused on a fixed point  Do not perform in trauma patient!  Positive Doll’s Eyes?

19. General Approach  Oculovestibular Reflex  Torso inclined 30º  50ml cold water into ear  COWS:  Cold water causes nystagmus toward contralateral ear  Warm water causes nystagmus to ipsilateral  Conscious patients may vomit  Test both sides: may be asymmetrical

20. General Approach: Physical Cranial Nerves: Corneal reflexes  Indicative of depth of metabolic coma  Absent 24 hours after trauma / cardiac arrest indicates poor prognosis  May be diminished in conscious elderly, diabetic, or optho patients due to loss of sensation of cornea

21. Toxidromes  Pinpoint pupils, decreased respiratory effort and rate, hypothermia, AC scars  Widely dilated pupils, moderate tachycardia (120’s), flushed skin, dry skin  Hyperthermia, tachycardia, tremor, myoclonus, rigidity  Miosis, salivation, lacrimation, urination, defecation, emesis, bradycardia

22. Toxidromes  Pinpoint pupils, decreased respiratory effort and rate, hypothermia, AC scars  Widely dilated pupils, moderate tachycardia (120’s), flushed skin, dry skin  Hyperthermia, tachycardia, tremor, myoclonus, rigidity  Miosis, salivation, lacrimation, urination, defecation, emesis, bradycardia

23. Toxidromes  Pinpoint pupils, decreased respiratory effort and rate, hypothermia, AC scars  Widely dilated pupils, moderate tachycardia (120’s), flushed skin, dry skin  Hyperthermia, tachycardia, tremor, myoclonus, rigidity  Miosis, salivation, lacrimation, urination, defecation, emesis, bradycardia

24. Toxidromes  Pinpoint pupils, decreased respiratory effort and rate, hypothermia, AC scars  Widely dilated pupils, moderate tachycardia (120’s), flushed skin, dry skin  Hyperthermia, tachycardia, tremor, myoclonus, rigidity  Miosis, salivation, lacrimation, urination, defecation, emesis, bradycardia

25. Toxidromes  Pinpoint pupils, decreased respiratory effort and rate, hypothermia, AC scars  Widely dilated pupils, moderate tachycardia (120’s), flushed skin, dry skin  Hyperthermia, tachycardia, tremor, myoclonus, rigidity  Miosis, salivation, lacrimation, urination, defecation, emesis, bradycardia

26. Laboratory Testing  Serum labs  Radiography (Head CT)  Lumbar Puncture  EEG

27. Laboratory Testing: Serum  Accu-check is part of the ABCD’s!  Electrolytes essential to r/o metabolic  Na, BUN/Cr, anion gap  Consider  UA, urine and blood cultures  TSH  Carboxyhemoglobin  Drug Screen and EtOH level

28. Laboratory Testing: CT CT is initial test of choice (better for blood than MRI)

29. Laboratory Testing: LP  Head CT before LP recommended for possible mass lesions  DO NOT DELAY ANTIBIOTICS/ STEROIDS! (you have the blood cultures...)  LP after CT if SAH suspected

30. Laboratory Testing: EEG  Indications:  Status epilepticus (SE) with paralysis  Suspected non-convulsive SE (NCSE)  Aid in diagnosis of unknown case  8 of 236 patients without overt seziure activity in coma had NCSE  Pattern may indicate cause of coma (metabolic, structural, seizure, anoxic)

31. Case #1  78 yo male BIB RA from SNF for fever and altered mental status  Temp 40º, HR 110, BP 95/60, R 20  PE: dry mucous membranes, poor tugor  Minimally responsive, groans when neck flexed, hot to touch  UA normal

32. Case #1  Blood Cx  Dexamethasone 10mg q 6hrs  Vancomycin and Ceftriaxone  Head CT  LP

33. Case #2  42 yo male of “no fixed abode” BIB police after found down in street  Pt is “well known to service”  Vitals normal except mild hypothermia  GCS 9 (withdraws and moans to pain)  Odor of EtOH on breath

34. Case #2  Pt left in back room for 4 hours to “sober up”  Found seizing  Further exam found a hematoma to left parietal scalp

35. Case #3  46 yo male alcoholic BIB family for decreased consciousness  He moans in response to stimulation, withdraws from pain, eye remain shut  Skin is jaundiced, sclera icteric  Foul breath (fetor hepaticus)  Abdomen: swollen, caput medusae

36. Case #3  Intubation?  Low grade cerebral edema sec. to NH 4  Lactulose, neomycin, rifaximin  Differential dx?  Precipitating causes (GI bleed, benzo, infection, etc)

37. Case #4  22 yo male BIB police for odd behavior  He was found in the street yelling  Agitated, combative, anxious  BP 184/97, HR 140, R 22, T38  Eyes open to pain, moves all 4’s, incomprehensible sounds  Eyes have rotatory nystagmus

38. Case #4  Used PCP  Essentially adrenergic toxidrome  Hallucinogen  Causes all forms of nystagmus

39. Case #5  39 yo female found down by husband  Had complained of a headache earlier  PMH: Htn  FHx: polycystic kidney disease  BP 150/90, HR 65, T37  Eyes closed, withdraws to pain, no verbal

40. Case #5  CT: 93% sensitive, 99% specific for SAH  CT Angio probably more sensitive  LP still needed to rule out definitively  Transfer

41. Case #6  27 yo female BIB family for odd behavior  Previous history of bipolar d/o  Now not responsive  No signs of trauma or intoxication  Exam normal except for intermittent nystagmus and eye deviation  All labs, including head CT and drug screen WNL

42. Case #6  EEG revealed persistent seizure activity  Pt has no myoclonic activity on exam  Non-Convulsive Status Epilepticus  Mental status improved with giving lorazepam

43. Conclusions  ABC-D (D is for Dextrose)  If elevated or low Temp would change your management, get a core temp  Less than 8, in-tu-bate!  For meningitis: IV, then blood cultures, then steroids, then Abx, then CT, then LP  Beware of occult trauma in the intoxicated

44. Any Questions?