Adult coma evaluation and treatment
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Adult coma evaluation and treatment involves a full neurological examination including vital signs and Glasgow Coma Scale. Initial screening tests such as bloodwork, CT scan, and EEG are used to determine the cause of coma. Management focuses on stabilizing ABCs such as intubation, oxygen supplementation, IV access, and treating seizures. Empiric treatments may include antibiotics for possible infection, naloxone for possible overdose, and mannitol or lorazepam to manage increased intracranial pressure or nonconvulsive seizures. Neurological exams like the oculocephalic response and caloric response tests help evaluate brain stem function.
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Adult coma evaluation and treatment
- 2. Adult coma evaluation and treatment Evaluation Vital signs and general examination Neurologic examination and GCS Screening laboratories (CBC, glucose selectrolyes, BUN, creatinine, PT, PTT, ABG, LFTs, drug screen) ECG Head CT scan: prioritize emergent if focal neurologic signs,papilledema, fever Lumbar puncture:prioritize emergent after CT scan if fever, elevated WBC, meningismus; otherwise do according to level of suspicion for diagnosis or if cause remains obscure EEG: for possible nonconvulsive seizure, or if diagnosis remains obscure Other laboratory tests:blood cultures, adrenal and thyroid tests,coagulation tests,carboxyhemoglobin, specific drug concentrations -do according to level of suspicion for diagnosis or if cause remains obscure Brain MRI with DWI, if cause remains obscure Management ABCs: Intubate if GCS ≤8 Stabilize CSpine Supplement O2 IV access Blood pressure support as needed Glucose 50 percent IV 50 mL (after blood drawn, before results back) Thiamine 100 mg IV Treat definite seizures with phenytoin or equivalent Consider empiric treatments: For possible infection: Ceftriaxone and Vancomycin Acyclovir For possible ingestion: Naloxone Flumazenil Gastric lavage/activated charcoal For possible increased ICP: Mannitol For possible nonconvulsive status: Lorazepam Phenytoin or equivalent GCS: Glasgow coma scale; CBC: complete blood count; BUN: blood urea nitrogen; PT: prothrombin time; PTT: partial thromboplastin time; ABG: arterial blood gas; LFT: liver function tests; ECG: electrocardiogram; CT: computed tomography; WBC: white blood cells; EEG: electroencephalography; MRI: magnetic resonance imaging; DWI: diffusion weighted imaging; ICP: intracranial pressure.
- 3. Oculocephalic (doll's eyes) response: This test should not be performed if a cervical spine injury is suspected. Observe the motion of the eyes while passively moving the head. In a comatose patient, conjugate movement of the eyes in the direction opposite to the head movement is expected. An absent or asymmetric response in an unconscious patient implies brain stem dysfunction. Caloric response: After visually checking that the tympanic membrane is intact, ice cold water is used to irrigate the ear canal and should produce a slow conjugate deviation toward the irrigated side. An absent or asymmetric response indicates brain stem dysfunction.