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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Eelco's BookThe Comatose Patient
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
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…