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The Unconscious Patient (Differentials (Metabolic (DKA, Hypo/hyperglycemia…
The Unconscious Patient
Definitions
Coma: results from sustained impairment of awareness of self and of the environment. It can simply be defined as a state of unconsciousness or numerically categories as a GCS score of <8.
Differentials
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Toxin/Drug-induced
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Overdose (opiates, tricyclics, benzodiazepines)
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Investigations
Bedside
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Urinalysis: Ketones will be present in DKA. The urine should also be sent for toxicology analysis if poisoning is suspected.
Bloods
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TFTs: increased TSH, low T4 with hypothyroidism
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Special
Lumbar Puncture: meningitis, SAH
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History
Presentation: trauma, drugs, DKA, poisoning, hypothermia
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Trauma
Diffuse axonal injury: results from severe shearing forces on the brain, a sequel to rapid acceleration and deceleration forces.
Extradural haemorrhages: as a result of skull fractures with laceration of meningeal arteries. Hx: of TOL, a lucid interval in which the patient feels and appears well, followed by drowsiness, headache, vomiting, progressive hemiplegia and eventually coma.
Subdural Haemorrhages: laceration of the bridging veins. Chronic subdural haemorrhages may occur in the absence of trauma - elderly are predisposed to this due to cortical atrophy.
Headache prior to coma: trauma, SAH or meningitis (meningism). Progressive headache - worse in mornings and associated with vomiting, may be due to raised ICP from a cerebral tumour
Predisposing Factors: DKA, hypoglycaemia, known RF or LF, severe hypothyroidism, suicide attempt? Known mental health? Post-ictal?
Collateral History: relatives, paramedics, witnesses, GP
Examinations
Temperature
Body temperature should be recorded and a series of normal body temperatures will exclude hypothermia and hyperpyrexia as a consequence of heat stroke or illicit drug use
General Examination
Thorough inspection: remove clothing, log rolling (examine the back), examine scalp for bleeding, haematomas or fractures.
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Neurological Examination
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Assess tone, reflexes and babinski response (unilateral hypertonia, hyperreflexia and upgoing plantars --> stroke, intracranial haemorrhage or tumour)