Evaluation of Pseudocoma VS Coma

Evaluation of Pseudocoma

Difference Pseudocoma VS Coma

Here is a short table to quickly differentiate a patient with pseudocoma from true coma

How to approach an unconscious patient in Emergency Department

How to approach an unconscious patient in Emergency Department:

One of the most challenging approach is to an unconscious patient presenting to emergency department. An emergency physician needs to keep him/herself gathered to approach a patient like this; in order not to miss a life threatening condition in a silent patient.

The 4 core components of care, history, examination, investigation and treatment should go in parallel. A systematic & structured approach should be employed by teams caring an unconscious patient i.e. ABCDE (Airway, Breathing, Circulation, Disability, Exposure), Vital signs, CPR, Intubation or Oxygen?, Blood samples, To give Glucose and/or Thiamine, History, Examination & Observation, etc

All steps should be followed simultaneously giving importance to TIME.

Time Constrained Approach:

'Time is Brain, Time is Heart'

What can kill the patient first?
Initial thought is 'How to make the patient survive next few minutes' then 'Further Minutes of survival' and then 'Hours' and 'To survive this event'.

Within First Minute:

First thing first:

Simultaneously Assess for:

1. Cardiac Arrest: Check Pulse
2. Airway: While checking pulse, assess airway patency and look for any Foreign body if obvious
3. Breathing: Pattern of breathing

All these things will be ongoing while the nurses are doing the vital signs and connecting to the cardiac monitor/defibrillator. Also accessing 2 IV lines and extracting blood.

Lets take it here: 

1. If cardiac arrest>>>> Proceed to Basic life support and start CPR

2. Airway & abnormal breathing>>>Assisted ventilation / Intubation (Intubate if necessary to protect airway)

What next to do:: 

Very Important part of Vital sign is:

Blood Sugar>>>> check for hypoglycemia, it should never be overlooked

If Hypoglycemia: treat hypoglycemia with:

-Inj D50% 50ml 1-2 Ampoules IV 

Patient of hypoglycemia be:

1. Low blood sugar 2.8 to 3.0 Mmol/dl or 50 to 54 mg/dl
2. Return to usual state after Dextrose bolus
3. No residual deficit

The above 3 point should be there to determine if all the symptoms of patient were due to Hypoglycemia

What else can Kill patient in next few Minutes:

-Drug overdose

-Intracranial Hypertension

While assessing these, simultaneous quick survey is important.

Assess for:

• Signs of Shock: Capillary Refil/Cold or Warm Skin
• Neuro: Check Pupils, Eye movements, Corneal reflex, moving all 4 extremities, any asymmetry?
• Toxidrome: Pupils, Vital Signs, Skin
• Breathing Pattern: Regular, Irregular
• Abdomen: Any signs of Pulsating masses, Pain?
• Chest: Any sign of tension Pneumothorax, deformity?
• Trauma: Any obvious deformity or trauma?

Toxidromes: 

• In case of Opioid toxicity: Inj Nalaxone 0.2-0.4mg IV, start at lower doses if patient is stable to avoid precipitating rapid opioid withdrawal.
• Wernicke's ncephalopathy: Inj Thiamine 100mg IV

Signs of impending herniation: Intubate; provide analgesia and sedation; elevated the head of the bed; respirate to a target pCO2 of 35mmHg; Mannitol 0.5-1gram IV or 3% hypertonic saline 2-3ml/kg IV bolus.

What else should be done simultaneously:

Always remember H & T's of ACLS

H(HYPOGLYCEMIA, HYPERKALEMIA, HYPOTHERMIA, HYPOXIA, HYPOVOLEMIA, HYDROGEN ION(Acidosis)

T(Toxins, Tamponade(cardiac),Tension pneumothorax, Thrombosis (coronary and pulmonary), and Trauma)

• ECG: check rate, abnormal rhythm, look for Ischemia, Hyperkalemia (Confirm by STAT VBG) (be prepared for Pacing/Defibrillation)
• Portable Chest X ray: Hemo/Pneumothorax
• Bedside U/S: RUSH Exam

What Can threat patient's Life here:

• STEMI: Stabilize patient, Cath Lab activation
• Pulmonary Embolism: Tachycardic, Hypotensive, Sob, Arrested> Thrombolysis, Deteriorating patient>thrombectomy
• AAA: Stabilize and early involvement of Vascular / Cardiology/ Critical Care specialist
• Tension Pneumothorax: Needle decompression via large bore in 2nd intercostal space midclavicular line
• Hypotension: Start IV fluids/ blood products according to context
• Anaphylaxis: Inj Epinephrine 1:1000 (each ml contains 1mg of 1:1000) intramuscular should be given with following dosage
• Age More than 12 years/ Adults:  0.5mg (500mcg) IM (0.5ml of 1:1000 solution)
• Age 6-12 years: 0.3mg I/M (0.3ml of 1:1000 solution)
• Age 6 Months to 6 years: 0.15mg IM (0.15ml of 1:1000 solution)
• Less than 6 Months: 0.01mg/kg IM (0.01ml/kg of 1:1000 solution)
• Hyperkalemia: Inj Ca-Gluconate 10% of 10ml over 10min (equal to 1gm of calcium gluconate), Prefer Inj Calcium chloride in patients with cardiac arrest instead of calcium gluconate because the chloride formulation has approximately 3 times the amount of elemental calcium compared with the gluconate formulation.
• Treat Seizures with anticonvulsants
• Consider Encephalitis if altered LOC with fever history and start Acyclovoir

What else?

After initial approach so far which an emergency physician completes within 10-15min simultaneously managing appropriately, there are wide differentials to get lost in.

Stay systematic and think of further differentials which can pose risk at patient's life:

• Hypertensive emergencies/ Intracranial hemorrhage 
• Delirium Tremens/ withdrawl
• Infection like Necrotizing fasciitis: Look for sites of infection
• Metabolic disorders like DKA, HHS, severe hyponatremia
• Addisonian's Crisis
• Myasthenic Crisis

Stablize, Stabilize, Stabilize

Before shifting patient to Radiology department for CT Brain

Look for further differentials :

Mnemonic which is easy to remember

AEIOU TIPS

GCS

Evaluation of Pseudocoma Table can be seen here