Mayo Clinic Flagler COMA Stroke Education Day May 3 2019physicians.flaglerhospital.org/.../CME/2019-Stroke...May 03, 2019  · •Concern for ischemic stroke • CT with contrast •Concern

W David Freeman, MD

Professor of Neurology and Neurosurgery

No conflicts of interest or disclosures

Mayo Clinic Flagler Stroke Education Day

May 3rd 2019

COMA

Approach to the Comatose Patient

Objectives • Perform a neurological

coma exam • Assess ABC’s • Differential Diagnosis of

coma • Management

Neurocrit Care. 2015 Dec;23 Suppl 2:S69-75. doi:

10.1007/s12028-015-0174-1.

Coma – What is it?

Arousal: wakefulness, eye opening

Awareness: able to follow commands, content processing

Checklist for the 1st hour ☐ Evaluate/treat ABC’s and C-spine

☐ Rule out/treat hypoglycemia or opioid overdose

☐ Obtain Serum chemistries, ABG, urine toxicology screen

☐ Obtain emergent cranial CT to evaluate for structural stroke causes

☐ Determine if coma etiology is structural or non-structural

Approach to the Patient with Coma

Assess level of consciousness

IV access

Airway

Breathing

Circulation

C-spine immobilization

Approach to the Patient with Coma • Hypoglycemia

• Blood glucose < 70mg/dL (3.9mmol/L)

• 50ml of 50% dextrose

• Thiamine 100 mg IV before dextrose in patients at risk for nutritional deficiency

• Opioid Toxicity

• Naloxone 0.04-0.4mg IV repeated up to max dose of 4mg

Case Unresponsive Patient 75 year old male

Unresponsive to voice

Found in hotel room by housekeeping

Last known well last night (10pm)

Brought to the ED by EMS

Neurological Assessment 1) Level of responsiveness 2) Brainstem assessment 3) Evaluation of motor

responses, tone and reflexes 4) Appraisal of breathing

patterns Note any asymmetry in the examination

Level of Responsiveness (Coma scales)

• Eye opening

• Motor response

• Verbal response

Glascow Coma Scale (GCS)

• Eye opening

• Motor response

• Brainstem response

• Respiratory response

Full Outline of UnResponsiveness

Scale (FOUR)

Brainstem Assessment

• Pinpoint: raises concern of pontine damage

• Large, unreactive: midbrain damage, 3rd nerve compression

Pupillary Response

Corneal Reflex

Visual threat response

• Spontaneous

• Oculocephalic Reflex (Doll’s Eyes)

• Vestibulo-ocular Reflex (cold caloric testing)

Eye movements

Cough reflex

Gag reflex

Motor Function

Spontaneous movement or to noxious stimuli

Posturing in structural & metabolic coma

• Flexor (decorticate)

• Extensor (decerebrate)

Muscle tone

Reflexes

Distinguish between purposeful and reflex activity

Breathing

Breathing patterns may help localize

• Midbrain and Pons Neurogenic Hyperventilation

• Pons Cluster breathing

• Medulla Ataxic (Biot’s) breathing

Cheyne-Strokes- Cerebrum , OSA, CHF

Arch Neurol. 2006 Oct;63(10):1487-90.

Case Neurological Assessment

• Vitals: • Afebrile • HR 160 bpm • BP 105/70 mmHg • RR 12 /min • SpO2 100%

• GCS 3 (E1, V1, M1) • No evidence of trauma

Case Neurological Assessment

• Blood glucose normal

• Pupils are symmetric, reactive and enlarged to 8mm; eyes are dry

• Motor tone normal

• Myoclonic jerks are present

• He is intubated and ventilated for airway protection

• Bladder is distended (>1000cc urine)

• Wife is contacted over the phone Picture attributed to Nutschig at the English Language Wikipedia

Valuable clues to the etiology of coma

• Time course of unconsciousness • Abrupt • Gradual

• PMH, PSH • Meds, toxin exposures • Social history

Focused Presenting History and Past Medical History

Case

PMH MEDS

Coronary Artery Disease Aspirin

DM Type 2 Metformin

Depression Amitriptyline at night Desvenlafaxine daily

Recommended STAT Labs

LABS

☐ Bedside blood glucose, if not done

☐ Serum Chemistries

☐ Arterial blood gas

☐ CBC

☐ Toxicology studies: ☐ETOH ☐Urine toxicology screen

☐ Microbiology studies

☐ Consider co-oximetry

Initial Formulation

Causes of Coma

Neurologic Causes Toxic Metabolic Causes

Trauma (severe) Drug overdose

Neurovascular (stroke) Metabolic endocrine electrolyte hepatic, renal hypercapnea, hypoxia

CNS infection (encephalitis) Environmental toxins

Neoplasm (primary, metastasis)

Seizure/status epilepticus

Neuroinflammatory Autoimmune encephalitis, ADEM

Other: PRES, HIE

Back to the Case

Structural insult? (stroke/hemorrhage)

Hx CAD

rapid onset

abnormal pupils

motor exam & reflexes

Metabolic hx DM hx depression Medication overdose?

versus

Brain Imaging

Unclear cause or focal exam

• Noncontrast head CT STAT

• CT angiography (CTA) and CT perfusion (CTP)

• Concern for ischemic stroke

• CT with contrast

• Concern for CNS infection

Persistent Uncertainty

Additional testing

MRI

Lumbar puncture

Continuous EEG

Case Conclusion

• CT Head normal, EEG without seizures

• Labs show metabolic acidosis

• EKG shows widened QRS and prolonged QTc

• Tricyclic antidepressant toxicity suspected

• Treatment with sodium bicarbonate drip

• Within 36 hours, his EKG changes resolved and he woke up

• He admitted to overdosing his amitriptyline and desvenlafaxine

Handoff Checklist ☐ Clinical presentation

☐ Relevant past medical/surgical history

☐ Findings on neurological examination

☐ Relevant labs

☐ Brain imaging, LP, or EEG results if available

☐ Treatments administered so far

Questions?