So you have an unresponsive patient. The CT is negative. What now? Coma is tough! The differential is long and filled with many life threats. Today, I talk to Eelco Wijdicks about some specific questions regarding the evaluation of the comatose patient in the first few hours in the ED or ICU.
Eelco Wijdicks MD PhD is Professor of Neurology and Chair of the Division of Critical Care Neurology and currently practicing in the Neurosciences Intensive Care Unit at Saint Marys Hospital (Mayo Clinic Rochester). He is the founding editor of the journal Neurocritical care, the official journal of the Neurocritical Care Society.He has over 650 research papers,book chapters,topic reviews and editorials to his credit.
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The Comatose Patient
Coma Differential
Legend: Initial thoughts on coma in the ICU. This algorithm is a simplification of clinical practice. Localization and withdrawal motor responses are most probably not associated with brainstem involvement, and therefore the dichotomy is made. Once abnormal brainstem reflexes are found, two options are likely—acute hemispheric mass or acute brainstem lesion. Bihemispheric injury is structural or physiological and further differentiated into specific locations and suggestions for tests. ABG arterial blood gas, CSF cerebrospinal fluid, CT computed tomography, CTA computed tomography angiography, EEG electroencephalogram, SAH Subarachnoid hemorrhage
The Coma Neuro Exam
- Carefully examine the eyes (Vertical Skew, Anisocoria, Eye Movements)
- Check Brainstem Reflexes
- Check Tone
- Assess the FOUR Score
Full Outline of UnResponsiveness (FOUR) Score
FOUR Score Handout from the Mayo
Coma Review Articles
- Eelco's Amazing Article on Coma Basics
- Traub-Diagnosis and Management of Coma
- Why you may need a Neurologist to see a Comatose Patient in the ICU
Now on to the Podcast…
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Scott Weingart
Regarding the possibility of meningitis – what would be your approach to LP in a patient who’s on a not-easily-reversed antithrombotic agent? E.g. thienopyridines, Xa inhibitors. Standard teaching here is to never do an LP until the effect of these medications wears off, but a diagnostic delay of a week might not be practical in the case of thienopyridines – and depending on the indication, stopping that long might bring its own dangers.
Regards,
Maarten Van Hemelen
I.M. Resident
Belgium
Also worth consideration in the (not uncommon) scenario of the ICU patient, who perhaps presented for some presumably-identified problem (e.g. sepsis, DKA), but who remains persistently unresponsive or altered despite apparent correction of their underlying diagnosis: cefepime encephalopathy. In some datasets this is a surprisingly common phenomenon and can cause a spectrum of altered mental status including obtundation, delirium, abnormal movements (myoclonus), and non-convulsive status. Given the frequency of cefepime use in some centers this is definitely not a theoretical possibility, or even an uncommon one.
This comment stream got deleted during site restore: jneuro says November 17, 2016 at 01:45 I also think that the two settings (ER – coma of unknown origin vs. ICU – won’t wake up syndrome) are to be managed quite differently. The former (CUO-ER) deserves an algorithm just like trauma to free the mind and allow you to think about causes. The algorithm should mirror the prevalence of the various causes in your own ER, so that if you’re flooded with postictal comatose patients you might think about restricting CTAs to pts with focal findings, while other places might keep CTA in their algorithm for all CUOs. The Berlin algorithm might be a bit too coarse, but it is easy to implement (https://www.ncbi.nlm.nih.gov/pubmed/27121376) and it has well placed timeouts for the team to think. The latter (WWU syndrome) is much harder to standardize since the histories and trajectories of patients vary even more. I find that it is hard to keep an open mind in these cases, to not rush to a diagnosis. Wijdicks is a god Scott Weingart says November 18, 2016 at 12:24 Hi My Friend, Please add your name to all comments here, but yours is great… Read more »