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Evaluation and management of the comatose patient


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Evaluation and management of the comatose patient

  1. The initial steps are to control airway and ventilation, administer oxygen, maintain body temperature, and monitor vital signs, including oximetry and continuous ECG.

    2. If trauma has or may have occurred, immobilization of the spine, especially cervical, should be done immediately with a hard collar until radiographs exclude fracture or instability.

    3. An IV line should be secured, and adequate circulation should be established. Initial laboratory evaluation should include blood for glucose, electrolytes, BUN, CBC, calcium, ABG, cultures, liver enzymes, ammonia, prothrombin time (PT)/activated partial thromboplastin time (PTT), and blood type and screen. Blood and urine should be sent for toxicologic/drug analysis. A urinalysis should be performed.

    4. IV thiamine (100 mg), followed by dextrose, (50 ml 50% dextrose in water = 25 g dextrose) should be administered.

    5. IV naloxone (opiate antagonist), 0.01 mg/kg, should be administered if opiate intoxication is suspected (coma, respiratory depression, small reactive pupils). Naloxone may provoke opiate withdrawal syndrome in addicted patients. Flumazenil (benzodiazepine antagonist), 0.2 mg IV, may reverse benzodiazepine intoxication, but its duration of action is short. Flumazenil can cause seizures.

    6. The initial assessment should focus on a history of trauma, seizures, medications, alcohol or drug use, and existing medical conditions. The general physical examination may reveal a systemic illness associated with coma (e.g., cirrhosis, hemodialysis shunt, rash of meningococcemia) or signs of head trauma (e.g., lacerations, periorbital or mastoid ecchymosis, hemotympanum). The neurologic examination should localize structural lesions and diagnose brain herniation. Serial examinations should be performed to detect and intervene if clinical deterioration occurs.

    7. Herniation must be recognized and treated immediately. Treatment consists of measures to lower intracranial pressure while surgically treatable etiologies are identified or excluded
    a. Hyperventilation [carbon dioxide tension (PCO2), 2530 mm Hg] reduces intracranial pressure by cerebral vasoconstriction, usually within minutes. Reduction of PCO2 below 25 mm Hg is not recommended because it may reduce cerebral blood flow excessively.
    b. Administration of mannitol IV, 12 g/kg over 1020 minutes, osmotically reduces brain free water via the kidneys. The effect peaks at 90 minutes.
    c. Dexamethasone , 10 mg IV, followed by 4 mg IV q6h, reduces the edema surrounding a tumor or abscess.

    8. As soon as the patient's condition is stable, a head CT scan should be obtained to distinguish operable lesions (e.g., cerebellar hematoma) from inoperable lesions (e.g., pontine hemorrhage). Coagulopathy should be corrected if intracranial hemorrhage is diagnosed and before surgical treatment or invasive procedures (e.g., lumbar puncture) are performed. Each patient's circumstance should be carefully assessed before therapeutic anticoagulation is reversed.

    9. Lumbar puncture is indicated whenever CNS infection is considered and when subarachnoid hemorrhage (SAH) is clinically suspected but not confirmed by neuroimaging. One should not perform lumbar puncture if a mass lesion or midline shift is present on CT scan. In such cases, if CNS infection is suspected, appropriate broad-spectrum antibiotics and acyclovir should be administered without lumbar puncture. If cerebrospinal fluid (CSF) is obtained, it should be sent for cell count, protein, glucose, Gram stain, herpes simplex virus polymerase chain reaction, acid-fast stain, India ink stain, fungal and bacterial cultures, cryptococcal antigen, and bacterial antigens (particularly if antibiotics have been given). If possible, extra CSF should be saved and refrigerated.

    10. Electroencephalogram (EEG) is helpful in the diagnosis of subclinical electrical seizures (nonconvulsive status epilepticus). Some conditions have characteristic (not necessarily diagnostic) EEG findings, including hepatic encephalopathy, herpes simplex virus encephalitis, and barbiturate or other sedative intoxications.

    11. If the initial evaluation yields no diagnosis, a metabolic or toxic etiology is most likely. The patient should be admitted to an ICU with continued supportive care while additional diagnostic studies are pursued.

A 36 year old woman all of a sudden has some acute pain on the left side of her lower abdomen. She holds her side and has to sit down because of the pain. She is 36 years old and has two children. She had a tubal ligation at age 30. Her last menstrual period was 3 weeks ago and her menses have been regular each month with 4-5 days of menstrual flow. She has had an increasing amount of menstrual cramps in the last several years.
Of the following, which one do you think is the most likely cause of her pain?

A: acute appendicitis
B: bleeding ectopic pregnancy
C: ruptured or bleeding ovarian cyst
D: acute pelvic infection
E: torsion of ovary or fallopian tube

Answer is C
Ovarian cysts are the most common cause of sudden onset of pelvic pain in reproductive age women. They result from the normal process of follicle development or ovulation which has somehow failed to undergo its usual course. Follicles that do not develop into the main egg for ovulation that month usually just dissolve. The cyst that forms after the egg ovulates (corpus luteum) also usually dissolves when menses starts. If either of these two 'dissolving' processes fails to take place, a persistent cyst of the ovary may result.
Acute pain results either because of the pressure of a fluid-filled cyst or because of cyst rupture or bleeding. Frequently, physical activity will cause the rupture or bleeding.

this pt. had her Lmp 3 weeks ago.estrogen peaks around this time making ovarian cyst grow bigger and bigger.this cycle has been on going for some time until the cyst ruptured during this cycle.
on the other hand, I dont know the statistics if tubal ligation is associated with torsion of the ovary.
appy is not possible looking at the history.The same can be said of pid and ectopic rupture( LMP 3WEEKS AGO).

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