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coma

the comatose patient

introduction

immediate resuscitation

  • usual resuscitation measures addressing airway, breathing, circulation
  • check glucose level to exclude hypoglycaemia
  • if trauma possible, protect cervical spine
  • consider naloxone (Narcan) 0.1mg/kg (max 2mg) im/iv/intranasal in case opiate overdose, particularly if intravenous drug users (IVDU) or injection drug use (IDU) or pinpoint pupils
  • if evidence of seizures, Mx as per seizures, but be aware that hypoxia, shock, eclampsia and hypoglycaemia can all be the cause.
  • move to a resuscitation area as soon as possible for ongoing cardiorespiratory and neurologic monitoring
  • if persistent coma with GCS < 9 and no readily identifiable reversible cause, and no NFR status, consider intubation to protect airway and ensure adequate ventilation.

baseline investigations for undifferentiated reduced cognitive states

consider
  • CT brain
  • lumbar puncture (LP) if CT brain nad and no C/I
  • CXR
  • blood culture if possibly febrile illness
  • toxicology - eg. blood ethanol, salicylate, etc.
  • ammonia
  • metabolic screen in children
  • cortisol if possible adrenal crisis

investigate and Mx cause if not already evident

if fever

  • if history of febrile illness, petechial/purpuric rash or neck stiffness consider:
  • if history of febrile illness and hypotensive or clinically in shock, consider septic shock
  • if fever and young child with no sinister features, consider febrile convulsion
  • if recent international travel, consider:
    • cerebral malaria
    • typhus, yellow fever, trypanosomiasis, typhoid
  • NOTE: many of the conditions below also cause a raised temperature, and some are often precipitated by infections (eg. hepatic and Wernicke's encephalopathy)

if no history of fever

coma.txt · Last modified: 2019/01/20 10:22 by wh