The Comatose
Patient
Hans House, MD, FACEP
Professor
Department of Emergency Medicine
University of Iowa
Objective
 Outline the general approach to the
patient with stupor or coma, including the
use of clinical, laboratory, and imaging
investigations
Pathophysology
Initial Management
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A: Airway control if needed
B: Assist ventilations, 100% O2
C: Volume if hypotensive
D: Dextrose
 Consider: glucose, thiamine, nalaxone
Differential Diagnosis
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A - alcohol, anoxia
E - epilepsy
I - insulin (diabetes)
O - overdose
U - uremia, underdose
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T- trauma
I - infection
P - psychiatric
S – stroke / sub-arachnoid
Differential Diagnosis
Most common ED diagnosis:
 Trauma
 CVA
 Intoxications
 Metabolic
 Post- ictal state
 Post- cardiopulmonary arrest
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.
General Approach: History
“Further history limited to
patient’s medical condition”
General Approach: History
Ask family, EMS, chart:
 Time course of onset
 Duration of symptoms
 Focal signs
 Past Medical History
 Medications
 Alcohol or drug use
General Approach: Physical
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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
General Approach: Physical
 After nervous, skin is
the most useful system
to examine
 Trauma
 Infection
 Toxidromes
 Jaundice
 Seizure trauma
 Rhinnorrhea
General Approach: Physical
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Nervous System
Assess and document level of arousal
Useful for prognosis, not diagnosis
Use GCS
“Less than eight, in-tu-bate!”
General Approach: Physical
 Assessing level of arousal
 Shouting, sternal rub, pinching trapezius,
nailbed pressure
 Supraorbital pressure? Smelling Salts?
General Approach: Physical
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Motor function
Unable to do routine oppositional force
Use reflexes
Look for asymmerty
General Approach: physical
Cranial nerves: Pupils
 Supertentorial mass/ hemorrhage or
primary brainstem lesion
 Disruption of 3rd 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
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
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)
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?
General Approach
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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
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
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
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
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
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
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
Laboratory Testing
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Serum labs
Radiography (Head CT)
Lumbar Puncture
EEG
Laboratory Testing: Serum
 Accu-check is part of the ABCD’s!
 Electrolytes essential to r/o metabolic
 Na, BUN/Cr, anion gap
 Consider
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UA, urine and blood cultures
TSH
Carboxyhemoglobin
Drug Screen and EtOH level
Laboratory Testing: CT
CT is initial test of choice
(better for blood than MRI)
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
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)
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
Case #1
 Blood Cx
 Dexamethasone
10mg q 6hrs
 Vancomycin and
Ceftriaxone
 Head CT
 LP
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
Case #2
 Pt left in back
room for 4 hours to
“sober up”
 Found seizing
 Further exam
found a hematoma
to left parietal
scalp
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
Case #3
 Intubation?
 Low grade cerebral
edema sec. to NH4
 Lactulose, neomycin,
rifaximin
 Differential dx?
 Precipitating causes
(GI bleed, benzo,
infection, etc)
Case #4
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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
Case #4
 Used PCP
 Essentially adrenergic
toxidrome
 Hallucinogen
 Causes all forms of
nystagmus
Case #5
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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
Case #5
 CT: 93% sensitive,
99% specific for SAH
 CT Angio probably
more sensitive
 LP still needed to
rule out definitively
 Transfer
Case #6
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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
Case #6
 EEG revealed
persistent seizure
activity
 Pt has no myoclonic
activity on exam
 Non-Convulsive Status
Epilepticus
 Mental status improved
with giving lorazepam
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
Any Questions?