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A systematic approach to low GCS MIND THE BLEEP TEACHING SESSION – 28/04/2022TRAR, HEE SWP PRODROMOS.ANASTASIADIS@NHS.NETVevox app link for polls https://vevox.app 185-147-681 Why learn about the unconscious patient Not uncommon presentation to ED, on the wards Α sign of deteriorating patient Diagnosis can be challenging Learning Objectives Terminology and pathophysiology of reduced consciousness states Systematic approach to history, examination, investigations and diagnosis of coma The Red flags – The 8 questions you need to answer ASAP about the comatose patient A few points in management of coma/reduced consciousness states A few points about prognosisNot included in this topic An extensive review or approach/risk assessment of transient loss of consciousness (syncope, resolved seizure) Recommend reading: - Transient loss of consciousness ('blackouts') in over 16s [NICE guidance 2010] consciousness (‘blackouts’) in adults and young people (NICE) Practical Neurology 2011;11:108-110.Introduction - Definitions Consciousness State of alertness and awareness of oneself Coma State of closed-eye* unresponsiveness to external stimuli; eye opening to pain without fixation or tracking and limb withdrawal to pain at best Levels of consciousness Difficult to define degrees of coma. There are scales, eg Glasgow Coma Scale which allow better communication between professionals … and something additional? Use scores but also describe examination findings eg patient tracking when eyes opened, before only looking straight etc as allows more accurate comparisonAnatomy Coma: InterruptionAscending Reticular Activating System Dorsal brainstem -> projecting to thalamus (bilaterally) -> projecting to ipsilateral cerebral cortex (either side) In thalamus, particularly important the intralaminar nucleiAnatomyAnatomy Pathophysiology As per these neuroanatomical localisations, coma is generally caused by the following aetiological categories: - Structural injury to cerebral hemispheres (bilateral, or major unilateral if there is midline shift/brainstem displacement) or bilateral thalami - Structural brainstem injury (or compression) - Acute (systemic) metabolic or endocrine derangement - Diffuse/global brain dysfunction (eg seizures, toxins, infection)General approach - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - Prognosis Join: vevox.app ID: 185POLL OPEN Case1 You are walking upthestairs toyour flat,you hear aneighbour shout “help” inthe corridor. You walkintotheirflat,theirpartner islying on thefloor,seemingly unconscious. What doyou do? 1. A. Ask you neighbour what happened 21.43% 2. B. Approach and check the unconscious person's pulse 64.29% 3. C. Call an ambulance 14.29% 4. D. Check your pulse 0%Out of hospital unconscious patient • Stabilise – BLS, ABCDE • Call emergency services • Look at the time on you watch • Limited ABCDE – don’t forget glucose levels (especially in a diabetic)!General approach - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - Prognosis Out of hospital unconscious patient History Basics; follow your usual history taking structure from witnesses/relatives/bystanders: • age, gender, L-R handed, profession (environmental exposures) • onset of symptoms (how long unconscious, any trauma?, breathing at all times?, when last seen completely well), •pains, breathlessness/stridor/wheeze, any recent gradual decline in consciousness),on, chest •cardiovascular disease, epilepsy),ndocrinopathies, renal or liver failure, depression-overdoses, • drug history (taken all medication, any recent omissions), • environmental history (smoke inhalation, illicit drug use)General approach - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - Prognosis Out of hospital unconscious patient Examination may be challenging in an out of hospital environment. By a limited (by equipment) ABCDE: • Pupils +/- eye movements and eye deviations • Glasgow Coma Scale (eye opening, voice/speech, motor response to pain – note down if any asymmetry in responses) • Any obvious abnormal movements (eg seizure-like) would need to be clearly described.General approach - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - PrognosisOut of hospital unconscious patient The emergency services have arrived. You give a clear, detailed handover to the paramedics and provide contact details, advise other witnesses to do the same, ask them to try and be available for communication by the hospital later today, for further enquiries and updates.In-hospital cases You are a medical Registrar doing a locum shift in the ED. A patient is blue lighted to Resus, after they were found unconscious in their home. What do you do?In-hospital, first assessment of unconsciousness - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - PrognosisIn-hospital, first assessment of unconsciousness History Print ambulance sheet if possible. Collateral history – early accurate history will improve patient outcome.In-hospital, first assessment of unconsciousness Examination ◦ Neurological examination ◦ General physical examination In-hospital, first assessment of unconsciousness Neurological Examination is generally limited to what can be examined • Coma scale ◦ Glasgow Coma Scale ◦ The FOUR score • Cranial nerve examination • Breathing patterns • Motor examination Join: vevox.app ID: 185-147-681POLL OPEN Case2-Apatient arrives totheEDafter theyare unconscious intheir garden. They have eyes closed and donot open them despite painful stimuli, though they are making odd groaning sounds and theybring theirright hand totheir left shoulder to remove thehand that ispinching them. What istheirGCS? 1. A. 11 11.76% 2. B. 8 76.47% 3. C. 2 11.76% 4. D. 16 0%In-hospital, first assessment of unconsciousness Glasgow Coma ScaleIn-hospital, first assessment of unconsciousness FOUR score In-hospital, first assessment of unconsciousness Neurological Examination • Coma scale • Cranial nerve examination • Breathing patterns • Motor examination In-hospital, first assessment of unconsciousness Cranial Nerve examination • Fundoscopy • Pupillary responses • Blink Reflexes • Eye position • Spontaneous eye movements • Oculocephalic responsesIn-hospital, first assessment of unconsciousness Fundoscopy, in the context of coma assessment, is useful to check for ___In-hospital, first assessment of unconsciousness Fundoscopy, in the context of coma assessment, is useful to check for papilloedema, suggesting increased ICP PS. Think emergency CT head/CT Venogram In-hospital, first assessment of unconsciousness Pupillary responses • Asymmetric responses highly suggestive of structural lesion • Symmetric responses usually metabolic/toxic causes, but in some cases structural • Preexisting pupillary irregularities, eg cataract surgery, to be taken into consideration when deciding on significance Join: vevox.app ID: 185-147-68POLL OPEN Case3-Acomatose patient that wasbrought toED afterhe became unresponsive overafewminutes, whileat home withhiswife, has aleft pupilsmaller than the right one. Thedifference inpupilsizesgets bigger inlow light conditions. What isthe next best action? 1. A. Naloxone 0% 2. B. CT head with angiogram 92.31% 3. C. CT thorax -check lung apices 0% 4. D. MRI head 7.69% 5. E. Lumbar puncture 0% In-hospital, first assessment of unconsciousness Pupillary Responses – important points • Asymmetric responses • Large pupil unresponsive, think herniation syndrome (uncal herniation compressing ipsilateral 3 nerve) or Pcom artery aneurysm (compressing 3 nerve) – with coma possibly ruptured – Think emergency CT head + CT angiogram • Small pupil unresponsive (Horner’s syndrome) – may be related to lateral brainstem pathology •Pinpoint pupils (symmetric) • Think naloxone for opioid toxicity (pons pathology also alternative possibility, but no harm in naloxone)In-hospital, first assessment of unconsciousness Blink Reflexes Normal: Eye drops to each eye will cause blink to both eyes Afferent: V Efferent VII Join: vevox.app ID: 185-147-681 POLL OPEN Case4-Anunresponsive patient hashisblinkreflexes tested. When hisright cornea isstimulated, heonly closes theright eye, when hisleft cornea isstimulated, heonly closes theleft eye. Where isthelesion? 1. A. Right facial nerve 10% 2. B. Bilateral trigeminal nerve 30% 3. C. Midline pons 60% 4. D. Bilateral facial nerves 0% 5. E. Bilateral frontal lobes 0%In-hospital, first assessment of unconsciousness Blink Reflexes Normal: Eye drops to each eye will cause blink to both eyes Afferent: V Efferent VIIIn-hospital, first assessment of unconsciousness In-hospital, first assessment of unconsciousness Eye position and eye movements Think horizontal and vertical planes thalamic or pontine) or seizures/statusecause of stroke (hemispheric, Variety of abnormal movements (dipping, bobbing, ping pong etc) can reflect metabolic encephalopathy or brainstem damage Vertical –conjugate- downwards deviation: severe dorsal midbrain lesion th Skew deviation – brainstem lesion/4 nerve palsy One eye down and out – 3 nerve palsy In-hospital, first assessment of unconsciousness Oculocephalic responses • Head thrust manoeuvre (weaker stimulus in comatose patients) – Do not perform in trauma/c- spine injuries • Cold caloric responses (more demanding in resources, time, etc, not usually performed in acute setting)In-hospital, first assessment of unconsciousness A normal oculocephalic reflex (eg head thrust manoeuvre) suggests intact vestibulo-ocular reflex and thus more likely intact brainstem In-hospital, first assessment of unconsciousness Neurological Examination • Coma scale • Cranial nerve examination • Breathing patterns • Motor examinationIn-hospital, first assessment of unconsciousness •Breathing Patterns Cheyne-Stokes breathing can occur in any type of reduced alertness, not helpful in localising Other patterns (cluster or apneustic, central hyperventilation, ataxic) recognise/differentiate and not seen when patiento intubated/ventilated In-hospital, first assessment of unconsciousness Neurological Examination • Coma scale • Cranial nerve examination • Breathing patterns • Motor examination In-hospital, first assessment of unconsciousness Motor Examination • Spontaneous movements • If purposeful, by definition not comatose, work-up for encephalopathy • Non-purposeful – most important is polymyoclonus, caused by anoxic brain injury, but also lithium, cephalosporin and pesticide toxicity • Response to pain, reflexes and plantars are pretty much the only motor examination that can be performed in coma – look for asymmetry, be vigilant re: locked in syndrome (CNS or PNS aetiology) • Decorticate and decerebrate posturing not much localising value In-hospital, first assessment of unconsciousness General Physical Examination • Odours (ketoacidosis, ethanol) • General inspection (cachexia, self-neglect) • Skin (arterial puncture marks in IVDU, jaundice, dryness in barbiturate/anticholinergic poisoning, profuse sweating in neuroleptic malignant syndrome, serotonin syndrome) • Hypovolaemic signs (sepsis, overdose of antihypertensives, internal haemorrhage) • Cardiac arrhythmias (MI/recent cardiac arrest, result of medicationoverdose) •Addison’s hypoglycaemia) use, ethanol, sepsis, CNS infection, hypothyroidism, • Meningism In-hospital, first assessment of unconsciousness At all times, when first assessing an unconscious patient, try to answer • Could this be a major anoxic/ischaemic insult to the brain? • Could this be an intoxication? • Could this be a CNS infection? • Could this be hypoglycaemia or hyperglycaemia? • Could this be due to hyponatraemia? • Could this be non-convulsive status epilepticus? • Could this be an embolus to the basilar artery? • Could this be psychogenic?In-hospital, first assessment of unconsciousness - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - PrognosisRemember the Anatomy … and the potential aetiological categories As per these neuroanatomical localisations, coma is generally caused by the following aetiological categories: - Structural injury to cerebral hemispheres (bilateral, or major unilateral if there is midline shift/brainstem displacement) or bilateral thalami - Structural brainstem injury (or compression) - Acute (systemic) metabolic or endocrine derangement - Diffuse/global brain dysfunction (eg seizures,toxins, infection) Join: vevox.app ID: 185-147-681 POLL OPEN Case5-42Mbroughtinwithsuddenonsetrightsidedweakness, leftMCAinfarct, thrombolysed, thrombectomy. Laterintheday,droppedhisconsciousness level(GCSE4VAM6toE2VAM4). Planfor rescan,butinthemeantime alsodevelopsanisocoria, withleftsideddilatedandunresponsive tolight pupil.Whatisthelikelycause? 1 A. Further thrombosis in left MCA 0% 2 B. Post-thrombolysis bleed with brainstem compression 100% 3 C. Further thrombosis in basilar artery 0% 4 D. Pcomm artery aneurysm 0% 5 E. Iatrogenic/medication related unresponsiveness 0% Join: vevox.app ID: 185-147-681 POLL OPEN Case6-Youngepileptic admittedwithseizures, 3xGTCS,self-terminated. Patientstilldrowsy, 1hour postlastseizure. GCSE2V2M4. Noobviouslimbtonicorclonicmovements. Eyesshowaconjugate, rhythmic, upandrightdirectedmovement. Whatisthecause–whatisthenextstep? 1 A. Likely underlying brain lesion, needs urgent brain scan 40% 2 B. Ongoing seizure activity, no generalised movements so can observe 20% 3 C. Ongoing seizure activity, give benzodiazepines 30% 4 D. Unclear cause, request MRI and EEG 10%In-hospital, first assessment of unconsciousness - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - Prognosis Causes of coma A non-exhaustive list Wijdicks EFM The Bare Essentials Practical Neurology 2010;10:51-60. In-hospital, first assessment of unconsciousness Investigation approach – step-wise • Phase 1: History, examination, CT head, ECG, basic blood tests (include TFTs), ABG. Abnormal brainstem and normal CT head most likely basilar thrombosis – needs CTA • Phase 2: MRI, EEG, Lumbar Puncture. • Phase 3: Think less common toxins, consider coma mimicsIn-hospital, first assessment of unconsciousness - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - Prognosis Join: vevox.app ID: 185-147-681 POLL OPEN Case7-68M, 1weekhistoryofdeteriorating mobility overall.Referredduetoreduced responsiveness, gradually worse. O/E:Openseyesandmovesthemupanddown,blinksuponinstruction, butnot verbalising, nottracking eye movements, nomotorresponse topain(nomovement). Reflexesabsent, plantarsmute.WhatistheGCS? 1 A. 13 0% 2 B. 4 54.55% 3 C. 2 0% 4 D. 8 36.36% 5 E. 11 9.09% Join: vevox.app ID: 185-147-681 POLL OPEN Case7-68M, 1weekhistoryofdeteriorating mobility overall.Referredduetoreduced responsiveness, gradually worse. O/E:Openseyes, movesthemupanddownandblinksuponinstruction, butnot verbalising, nottracking eye movements, nomotorresponse topain(nomovement). Reflexesabsent, plantarsmute.Whereisthelesion? 1. A. Left MCA territory 10% 2. B. Thalamus 60% 3. C. Brainstem 20% 4. D. Spinal cord 10% 5. E. Peripheral nerves 0% Join: vevox.app ID: 185-147-681 POLL OPEN Case7-68M, 1weekhistoryofdeteriorating mobility overall.Referredduetoreduced responsiveness, gradually worse. O/E:Openseyesandmovesthemupanddown,blinksuponinstruction, butnot verbalising, nottracking eye movements, nomotorresponse topain(nomovement). Reflexesabsent, plantarsmute.Whatinvestigations/management wouldyouconsider? 1 A. CT head and angiogram +/- thrombectomy 61.54% 2 B. MRI head +/- aspirin 0% 3 C. MRI c-spine +/- referral to neurosurgeons 23.08% 4 D. NCS/EMG +/- trial IVIG 15.38% 5 E. Lumbar puncture +/- steroids 0% In-hospital, first assessment of unconsciousness Differential Diagnosis – The main coma mimics • Locked in syndrome (ventral pons eg basilar thrombosis) • Akinetic mutism (eg rapid neuromuscular condition, like aggressive GBS, or rapid neurodegenerative disease/ eg prion) • Severe catatonia • Functional/ Psychogenic unresponsiveness (NEAD, hand drop test, tickling of nose hair, resisting eye opening)In-hospital, first assessment of unconsciousness - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - Prognosis In-hospital, first assessment of unconsciousness Early management of coma (cautious as may be due to Cushing reflex), Correct Hypothermiasion or extreme hypertension Consider naloxone Treat major metabolic/electrolyte imbalances, eg glucose, sodium mannitol). If hypertensive bleed, reverse anticoagulation, manage hypertensionsition 30 degrees, eg Consider CNS infection treatment, arrange urgent/asap LP Reduced responsiveness is a symptom, not a condition – treat the causeIn-hospital, first assessment of unconsciousness - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - PrognosisNatural course of coma and prognosticationNatural course of coma and prognostication Prognostication is very much based on determination of the cause of coma, eg traumatic brain injury outcomes are hard to predict Some predictors, mostly used for anoxic brain injury (myoclonic status epilepticus, lack of pupillary/corneal reflexes, absent motor responses to pain, absent sensory evoked potential cortical responses, increased serum neuron specific enolase) Minimally conscious state (MCS) and Persistent vegetative state (PVS) are 2 states in which the patient may emerge after a comatose period. Natural course of coma and prognostication ongoing cardiac function. To diagnose brain death:ans complete loss of brain function despite •managedtential reversible coma causes and coma mimics need to have been explored and • All sedatives discontinued and core temperature >32C • Examination shows patient not arousable to stimuli, no pupillary or corneal reflexes, no vestibulo-ocular reflexes (ie no cold caloric reflexes), not gaging/coughing when suctioned. • Apnoea test used to confirm brain death. •Some cases supplementary investigations – EEG, SSEPs, no cerebral blood flow on transcranial Doppler, angiography, radionuclide cerebral perfusion scanningIn-hospital, first assessment of unconsciousness - Stabilise (patient may be at risk of imminent death) - History - Examination - Localise lesion if possible - Investigations (less clues from history and examination equals more/wider investigations) - Differential diagnosis - Management - PrognosisSummary Coma is a challenging presentation, usually unwell patient Successful management relies on keeping a high quality of the chain of diagnostics and handover, as accurate information will lead to appropriate investigations and conclusions causesssessing a comatose patient, ask yourself 8 questions and manage serious, easy to diagnose Approach investigations in a step-wise fashion Prognostication in coma will rely again on accurate, consistent information, accurate diagnosis and can be very challenging – usually a clinical decision, with some auxiliary tests Any questions? Feedback and Certificate link References • Gates . Work out where the problem is in the brainstem using ‘the rule of 4’Practical Neurology 2011;11:167-172. • Wijdicks EFM The Bare Essentials Practical Neurology 2010;10:51- 60. • Andrew Tarulli – Neurology: A Clinician’s approach. Chapter 2 – Coma • Brouns, Raf. (2004). Eelco F.M. Wijdicks, Catastrophic Neurologic Disorders in the Emergency Department, second ed. Clinical Neurology and Neurosurgery