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I Everyone thinks we have me another time. My name is problem with some, uh, ST poor of the southwest of England There for hospital in Plymouth. So I've been asked to give a talk on ah, systematic approach too low GCS equally. You could name it the approach to the unresponsive patient or the comatose patient on I'm going to give you if a few seconds do. If you want to look into this up because we have a few questions and the few, uh, poles that you might be able to participate and you know, becomes a bit more interactive. I'm gonna give you safe 10 seconds, 15 seconds to look into that So my toe will be. It's fairly related to the confusion took that I gave a month ago, but in in ways, it's different because it's, um, it's again an approaching unwell patient. Uh, the unconscious base is obviously an unwell patient. That's why it's important to learn about the a systematic roads. This problem and it's not an uncommon presentation to eat the or on the world's. You will be quite often be asked to see unwell, unconscious patients, um, as the DS a chose or f once awards, and it's obviously a sign of a deteriorating patients. So, um, most conditions. If you let them untreated for a period of time, they bound to arrive to accommodate oh state before sort of the inevitable happens on the diagnosis can be quite challenging. So in some ways, that's why it's been different from the approach to confuse patient. Because you have to deal a lot more with neurological examination and you have to have a good fundamental knowledge off. Some of the pathways in the brain stem the neurological pathways in the brain stem. You know, it makes sense of what you're examining, but where it will will go through all of that. But always be mindful that this is an approach to the to the problem. It's not and in depth analysis, off all the various sort of causes that lead to ah, comatose state, um, going to clarify fuel terms and ah way, I will give you a systematic approach, my approach through the history examination, investigations and finally diagnosis off comb Oh, on unresponsive states. Um, what is very important is for you to know some red flags, so I'll give you eight questions that you need to answer as soon as possible when you are asked to assess a patient who is unresponsive and that will lead to better outcomes for your patients, and we'll get you out of trouble as well. Um, it will give you a few points in management. Off they reduce the consciousness states and and a few points on prognosis. But we're not there too much into that, because I think it's, ah, it's beyond the scope of this presentation, and what I haven't included is an extensive review of the approach off management, off loss of consciousness states that transient loss of consciousness states such a syncope is, or seizures because these are covered in sort of other teaching sessions. And not this is a different approach than eso will be discussing on. Patients were currently unresponsive, not something that has a result on give some recommend. Recommend teaching here reading which you can you can check out on the transient loss of consciousness. Um, so consciousness is very brought them Ambrella tim. It generally states the alertness and awareness off some oneself and also their their wellness of the environment. Um, the coma again, a very sort of arbitrary definition. Off estate off closed I unresponsiveness, and I put an asterisk there because there are some, except exceptions, into that. But for the purpose of this learning session, comatose patients have closed eyes and the unresponsive to extend the stimuli, and they might open their eyes to pain without the sort of tracking or fixating on one specific object or yourselves that you're examined them on. The might withdraw the limbs, but usually that's that's about it. And there are different levels of consciousness, and that's why we're saying it is brought him on it. It's difficult, really, to define the degrees off consciousness. All the levels off the different levels of comes. But there are some scales, as we will discuss. For example, the most commonly used is the glass of a common scale that GCS and that's the type of this topic. This allows a better communication between professional. It's real important for you to know that I always remember, and that's my advice, at least to sort of myself. My colleagues scores are good. Even breaking down the disease is really important. But it's also important to describe Don't forget that the schools are just the skills that we have created. But don't forget to always give a bit more details on what information get from the patient. When you examine that, for example, the patients now bring the rise and they're tracking. They're looking at me. They seem to be more attentive compared to before, where they were briefly opening their eyes and looking lately. So that's important because it will give a better description of better, um, sort of observation of the patients changed or for consciousness levels. This's Ah, this is a Cartesian sort of chart that I've used using the previous presentation as well. As you can see, consciousness can be divided. Ah, in content off consists and level of consciousness. So there are these two different approaches to the, uh, the consciousness 10. And you can see that we can have different states and different situations with ah different contents and levels of consciousness, different mixes. So the common is obviously in the bottom left corner, and being in a normal consciousness, wakefulness and being aware of the environment and not being confused is the top, um, the top right. So as we as a sweet, be discussing. In this case, we will be discussing about mostly about the comedy states and not the other states. We'll talk a little bit about the minimally conscious state in the vicinity of states towards the end, So important bits off anatomy before we, um, start on the examination part. So comma is usually a result of an interruption off what we call the ascending reticular activating system s. So this is, um, a network with the start of the door, so brainstem and projects to the thalamus on both sides. Also in both calamine and from its thalamus, it projects to the lateral cerebral coat cortex. And in the followers, it's particular important that someone particular important structures are intralaminar nuclear. So this is a schematic. So, as you can see, we have the reticular activating system. Stopping at the dose, um, brings them and then goes all the way up to the calamine. So what is important for about this anatomy for you to understand is that obviously the brain stem is a small area, and the network so small damage can easily affect the network, whereas as we go a bit higher up so as we move from the brainstem towards the thalamus, you really have to have both sides effective in order to cause a real problem with the level of consciousness. So if you want to have a problem, if you have a claim practically, we have a brain stem problem you will easily have on either side. You easily have a problem with consciousness if it affects the door, so brainstem, whereas if you have one, one thumb was being affected rather than both. It's the patients less likely to be in a comatose state, much less likely and also in order for the cortices. Because ah ah, comatose state. You will have to come sort of a very extensive problem in both on both hemispheres, these this is just a schematic of the intron nuclear and intralaminar nuclear. You see how small they are? But how important there. Now, um as this is the anatomy that's relevant. So how how does comma, um, come about? So you can either have a structural injury to the cerebral hemispheres, as I mentioned on both sides or a very major unilateral side, if it pushes towards the midline and push towards the brace them So we're going back to the brain stem, essentially a with both Salamah ah, or a structure injury to the bracing. So mention that now the alternative way that you can have is you you can have comatose states is if you have a very diffuse a very ah diffuse global brain dysfunction. So if you have seizures that affect both hemispheres, we have toxins that affect the brain as a whole. If you have an infection that afraid that affect the brain as a whole, or if you have metabolic or endocrine changes those about to affect the brain as a whole. So if they're severe enough, they can cause it the structure global dysfunction of the brain and can lead to a comment of state. So in general, keep your mind on structure of problems and where those might be and in in a way, if we rule those out but also investigating for the other causes at the same time, then it's bound to be a diffuse metabolic or effectiveness or general diffuse problem of the grains. The approaches, in a way simple. The structure is simple. The general approach will have as a first step, stabilizing the patient because obviously a patient in a comatose state, especially if it's an acute comma, may be a risk of women and death or very, very severe disability, which you can do something about that you can also even reverse it, as we will see. Ah, and then you have your standard structure of history examination trying to localize the lesion on, then getting on with investigations based on what sort of opinion we have so far. That's what with your examination in history on and thinking about what he might not be. What So what other things that can be with maybe a coma. So we'll talk a little bit about that, and the management progress is at the end. So, um, maybe a few, uh, I'll give you a few seconds to read up on the first question. That's pretty standard. A basic. So you are. It's It's a common scenario. Well, not a very common one, I hope. But you're imagine that you're walking up the stairs to your flat, and then you hear your neighbor shot cry for help in the corner, and you tried to help them and you walk into their flat in their partner or person. Any person is lying on the floor and they seemingly unconscious. So it's just a question about what do you do? Ah, do you start to ask your neighbor what happened? And you go into much detail about that? These are all thoughts. By the way, do you approach and check the unconscious person's pulse or you check for science of life in general, We call an ambulance straight away or get check your pulse. Obviously, the last one is a joke. It's a reference through, uh, the House of God. It's a It's an excellent I'll give you a few more seconds. All right, you have 14 responses. Very good. So obviously no one checked their pools. But that seems to be that the first rule in a cardiac arrested, least a spare the House of God. I would recommend you to read the book. It's obviously all the, uh uh, you know, it's a funny It's a funny thing, but yes, So, um, I wouldn't say that all the first three once any of them is particularly wrong. So you probably do. You probably do a low. These things all together is in it. so you will ask what happened and approach You. Make sure that your surroundings are safe and call for help if, um if needed, which you probably need to, so I will not get into much of that. But you know, your A B C D is you'll be a less, um, it's again outside the scope, and I'm sure that you're very familiar with it. But you recognize Ah, the problem. You You most likely be very good at that. So if you see someone on well recognized a problem call for help, you go check for signs of life. Start CPR. We have to on you. Try to get as much information as you can, so but they're important for comatose states, especially, the pain is the person. It does not require CPR, so if they're so still breathing, but they're in comatose state. Very unresponsive is to get us much information as you can, so so continuing on to this specific example. So you do your stabilization. You call them by the services. Look at the time of your watch, so it's very important to time things because it will be important in when we assess information later on course with your your colleagues and hospital assessed information. And you do a limited A B C d. If the, for example, why you do that. If I was you getting the history of that, if you can ask quickly that you know is is the person diabetic? Yes, that you take the blood local. The blood glucose is one you know, like or you can trace it. They, you know, there you have it. You can reverse the school. This comatose state very quick. Um, no carrying on from stablization on the history. So you just use your own structure. You follow the usual history taking, which is obviously can be a bit difficult. So if you if you have put the patient in sort of recovery position, there's not much more you can do. You're trying to get a bit more information about what happened. So how old is the person? And they left the right hand that this will be helpful in stroke cases. Um, when did the symptoms start? How long have they been unconscious? Has that been any trauma? Any head injury? You can check as well while you're doing that. Have they been breathing at all times. So how when was the last time when they were seeing computer? Well, um, you can ask about them proceeding symptoms. They have any infections, any spirit of problems where the breathless before this happened, and the past medical history and drug history, especially if they have taken any medication at all recently, or if they have omitted any medication that they have started any new medication reason. And then you check for your check your environment. Obviously, you take for us for recreational drug use or if you see any sort of illicit drugs on around the person and you ask for a couple monoxide poisoning is one specific problem. So that's why in the chain off, um, survival, you always have to make sure your surroundings are safe, eh? So you just ask a simple question. Obviously, if someone called you for help and they were in the same room, it's unlikely to be the case carbamoxide pushing that, um, so move from the history to the examination. So being out of hospital is that this is the same scenario, and I would move on to vein possible scenario later because you will see that all these layers you just build up on simple layers and you go into more advanced and more complex things that you can do for your patient is, um, the examination of that state is a symbol A B C D. That you can start doing, um, so you can check the pupils on and see if they have I movements. And if their eyes are devoted to one side or the other. Um, you can check. You can do it, Blasco Coma scale. And you can see if there are any abnormal movements and you would you need to time and see and look clearly and be able to describe what you see. So I saw the person have clonic movements of the right arm and the face was pale or the job was cleansed. So thinks very simple description, descriptive terms, and this is just obviously the start off our approach. So that's why we're saying they're really up after I other foot unconscious patients, so you will not be able to do much for expression unless they have a simple thing that you can reverse or they need CPR and you have started that already But if they are in the recovery position and you have all this information, um, when the paramedics arrive, you you will give a very clear, detailed handle the paramedics and provide your contact details. You will suggest that the person who invited you to do the same to give you all the witness to give contact people's and ask them to be available for any communication that will come from the pasta later today. So the reason why I'm saying that is it might be scenario you will be involved in, but also this is what you will sort of request from the paramedics. So all of these little bits of history and all this information you will ask from the paramedics when they arrived to you or you will try to seek that information once the patient is in the hospital. So, for example, your medical release troubling a local shift In the most department, a patient is blue light to the recess of the found unconscious in the hole. What do you do? It's no different. So you will do the same things essentially. But you have more tools, you have more time and you have more sort of investigative ways in order to find exactly what's happening, and you can assess more calmly. You have other colleagues doing the same time the stabilization, for example, and you can order the investigation that can help you clarify, confirm or refute the the suspicion is that you have so again you will stabilize the patient, and you will take the history if you can. Obviously, you cannot take a history from the patient. So that's one important difference from your classic sort of presentations in the men's department or the hospital. But you can try to print the ambulance sheet, and you can try to get collateral history on. Obviously, you will not prioritise taking collateral history of stabilizing the patient. So these things always running parallel. So, um, if someone stabilize the patient, another person gets collateral history and the history questions that you will ask where the ones that we mentioned before So the all set the how quickly things progress, background, medical history and drug history off off the person. Um, the reason why I mentioned you know very might seem so trivial, but you you'll be surprised by how often we come to assess it patient. And I see you, for example. And there's no clear history of how the person ended up in I see you. So what I'm trying together is as a junior doctor. And even when you get more senior in, in very complex cases or in cases that will make a difference to it will make a difference to the patient if you have flare information. So look at it as a chain off events that happen throughout the Haitians. Admission to the hospital. So if you're a Lincoln, this chain always used to say, Try to be the strongest link. So trying to get the most history that you can Claritin put everything clear down in writing and you know, when you shift is over, maybe the problem will not be sold. But you were passed unclear information. You will add others to do the same. So you move on to the examination now, having had some collateral history, and I usually usually separate the examination, neurological examination in general physical examination. It will both move on to the neurological examination test. You will ask, What can I do to examine a basic was commenters Well, you could you consist the same generally what you can. So the the examinations limited the world can be examined when patients come up is obviously you cannot assess their language because they're unresponsive. So the main things that you have to assess is physical. Just have to confirmed that the patient is in a comment of state unresponsive rather than increase, fell a pathic because that would be a different approach, similar but different on different path. In meeting that it will be confused, they would be able to, you know, talk to you, but they will be confused and disoriented. But if if we're talking about the nonresponsive patient is in our cases here, you will try to perform a coma scale with you. Most likely have done already because you really Rabies See these and and then you move on from head down towards the toes, I say. But generally it's criminal never examination, and I will specify what exactly you can do in that you will check the breathing patterns off the patient that you have and you will be a motor examination. And the water examination is a specific specific things that you can check because obviously the person cannot follow really instructions. So limited examination, limited history so far. But the systematic approach will give you the answers that we want. So starting off with first steps off the examination. So I will have this case. Patient arrives to the amazed about department after they are found unconscious in the garden. So they have their eyes closed and they do not open them. Despite very painful stimulus. You pace, um, on the shoulder. You put pressure on the super orbital area, you might do, uh, you might push on the stand. Um, be careful with patients who have trauma, obviously not to exacerbate any problems with that, but you give them painful stimuli. They are making some groaning, groaning sounds, but they're not opening the rice, and they seem to bring the hand to the left shoulder to remove the hand. That's pinching that. So how would you calculate that? GCS. So talk about the GCS afterwards. Is this the, you know, just in entry question. Don't worry if you get it wrong. So this is a reminder because we would not have been responsive. Also, an ice voice and motor the components. So what do they do with their eyes, whether they do with that voice and how do they move their arms? Basically, And let's how do they do? How does he move them around? Okay, give you just a couple more seconds to get a few more responses in. All right. Okay. So, um, so Ah, yes. So you can see the results. But the essence of most of you say that it's a thing I don't quite remember. But essentially, their eyes will be one. Because they're not responding. The voice will be too, because they are so making some groaning sounds in general. Um, they're not completely nude, and they seem to be localizing. So they seem to be bringing their right side, the right arm, all the way to the left side just to push away. So they are localizing where the pain stimulus is, so that's pretty correct. So eight is the correct answer. So the easy way, just a few hints on the glass because my scale so the way I used to. So you have to repeat it. You have to sort of a repeat revised all the time about how how it is until until you remember it sort of clearly in your in your head, but essentially an easy way to sort of remember the steps for this we're not very familiar with. It is eyes the eyes, mouth and hand, eyes, mouth, hand. And you start with the The maximum points are 456. So 456. The minimum score is three, of course, and the maximum score is 15, so you don't have less than three. Ah, and the you try to remember what's the worst and what's the best response. And they in between you, you will be able to sort of a truck feeling as the time goes on. So you try to repeat and repeat a repeat, and you will. You will remember it clearly, and you will be able to do a D. C s within seconds. But essentially, you can have a little table until you you manage to do that. That's no problem there. There's also the four school, so that's another coma scale. That's a bit more specialists, and it's being used in your I see you setting. You don't tell me to use it up. Not practically seen it being used on a daily basis or sort of in common practice. But it is something that is, is a bit better than the glass glaucoma scale in terms, off sensitivity and specificity off levels of consciousness. And it's always said to remember it by heart. Now, obviously, this is the different project, and I can have a little sort of. You can check it on Google if you have to do it. But it's what we will be talking about. The different components off the four stories. The different brain stem pathology and the risperidone, every the risk responder e patterns that we will see in your patient. Um, so we've done our common skin, and then we move on to the cranial nerve examination. That's really important because it hits at the brainstem pathology and hinting at brains and pathology essentially means that there's a structural problem, right? S. So it's important to do it in your comatose patients. And if you have difficulty doing that, because some of that will or if you have problems interpreting the results, just write down what you have found and then seek help. It's no shame that it's quite complex there in Europe, pathways that you will see. So the first step is just to check the ice and you do a fundoscopy. We can, in the context of the conversations, usually check for a couple a Dema Um, that's mind you that this is before doing any city head scan or obviously, in daily practice, we have to see a see the head scan being done even before the patient is assessed in the most department. But it let's say you don't have immediate access to that. So we check for popular demon If you find bilateral publicly, my usually there's increased pressure in the brain. There must be something like a muscle Asian compressing on things and making the person being unresponsive. So you do a CT head, scalp and mind. You think about the CD venogram because often, um, you can have a venous Sinus reverses that causes the problem from from this could be you move on to the people, every responses. You probably be more familiar with that. But essentially, you said some light on both eyes and you check the responses that you take the immediate response e and you take the sort of indirect responses from the other people. Um, asymmetric responses will suggest the structural lesion until proven otherwise. Because, as you can see, you can have some papillary regularities because of cataract surgery, for example. But until proven otherwise, asymmetric response is highly suggestive structural lesions. So if you have a symmetric pupils, or if they don't respond fully the same way, you you should think about the structural lesions symmetric response. So symmetric pupils, the using said this metabolical toxic causes, so things that are more diffuse and will affect the whole brake. But there are cases where you can have, um, symmetrical pupils, which are abnormal, and the problem is the structure problem, and we'll see if you a few examples of that. So, uh, okay, ST. A comatose patient that was brought again to the emergency department after it became unresponsive for a few minutes well, at home with his wife, has a left pupil with the smaller than the right one. So left. People have been smaller than the right one, right, one bigger than the left one. The difference in people's eyes gets bigger in low light conditions, So if you turn off the lights, if you can do that in the Ms Department. Well, if you bring some shade over their eyes uh, the difference in people sizes. So how different? How bigger the one from the other is becomes even bigger in lower, like condition. What is the best next action? So obviously depends on what you think is the underlying problem. Um, and you can obviously, I will explain what I'll give you a few seconds again to think about it. Explain what the issue is obviously with with these descriptions because they look good on paper. But obviously, there's a It was a real life problem when we're assessing people's and give you a hint on that. Good, let's see the results. Good. So a lot of you would do, ah, see the head with angiogram and that's the correct one. The MRI head is know, obviously it's not. Ah, wrong answer, but it will take more time for it to happen. And we have some of whom became very suddenly unresponsive. And he was at home with his wife. Very similar response comes in, has a symmetric pupils. I mean, the basic thing that we have to think is this person has a symmetric pupils. There must be something structural. It's very quick. What can it be? So things that happens so quickly the you might should go to strokes. There is where I put the angiogram there. So essentially, that's Ah, that's a hint on assessing pupil assymetry. So when you have someone who has a same as dramatic pupils, it's often a bit difficult to find. It's not very straightforward to understand which people is the abnormal one eso. It will either be that the bigger people is the abnormal or the smaller people is the abnormal. And if you said some light and you know you haven't completely unresponsive people, then that's you know it will be pretty obvious which one it is. But if you have a response to both peoples, but they are asymmetric, so you have a symmetric, a symmetry and asymmetric responses. Then it's it's a bit more difficult. So what I usually do is I tried to find out which one is the abnormal fast, so if it's the bigger one of the smaller one, that is the abnormal. So if you have, um, ah, if you're in a normal like conditions and you bring a shade over the patient sizer or you turn off the lights and you say that the size like in this case, the difference in the pupil size is gets bigger. So you have a small people are bigger one and you put them under light and this difference becomes even bigger. So that means that the small pupil is the problematic on so the small people cannot enlarge in low light conditions. And that's why the bigger people want, which kind of large it becomes larger. And the difference is bigger. Eso that suggest that the small people is problematic so that the small covers problem. Until you have someone with the smaller pupil, what does that mean? They have a sympathetic problem. So, as I said, Don't you know, Don't feel overwhelmed by this. This will take a little bit of reading afterwards, but we're having an approach here, So asymmetry, structure, problem, a sympathetic problem here. In this case, it means that there's a wholeness problem, so there might be a problem with the lateral medulla Andi in the comment of space. So that might mean that they have It was still a circulation stroke, and that's where you do the CT angiogram because you might do it from back to me with thrombolysis if if we find evidence of that often, you know, if the rest of the examination success so you can go ahead and do a thrombolysis even without a little piece of information that you have. Yeah, but usually you can find a clot in the in the CT angiogram if if that's the cause of the problem. So I have a diagram here, feel free to take a photo of it or use it. The steel it It's not mine anyway, but I've borrowed it as well. But these are different patterns off pupillary changes that you can see in the different parts of people, every differences. So as you can see the first few once the first from any to the you have symmetrical and you can see that most of them not toxic a metabolic. But a few exceptions you can have fell Amit insults with Lamictal. Um, is that cause sort of mid sized people symmetrical midsize pupils, that you will have other problems So the examination needs to be taken it, you know, as a whole. So you can't just rely on the pupils, obviously, and midbrain remember that there might be mid sized big, bigger pupils with um are symmetrical is well, and the parents might give you a very small pupils. But the important once the EEG and F r the asymmetrical ones, because you might need to act eso a peek. Um, aneurysm. Obviously, the blown people so larger people is the abnormal one, whereas the lateral brain stem, that's the wholeness one. So the smaller one is the abnormal one. So the important parts, as I mentioned, if the last people is unresponsive. So if you said some light of the large people and it doesn't respond, or if again, as we said so, if in low light conditions the difference becomes smaller than rather than bigger, so the large people is problematic. So there is a problem with the parasympathetic fibers off the third now, so you might have a have effective pressure from the posterior communicating artery aneurysm, usually, or an uncle had any issues with the temporal lobe is compressing on the third. Now, the peripheral fibers are person pathetic fibers, and that causes the people to get to blow. As we say so the people become larger and unresponsive and the small people which is unresponsive to the homeless it like in the case that we mentioned. So if you have symmetric, symmetrical, pinpoint pupils first thing as we said, the polls can cause it. But first thing, toxic causes. So opiate toxicity is the first one. You will see it very often on the geriatric woods, someone or, you know, an orthopedic would. Somehow they're full, a hip fracture. And they had the opiate existing thing to give them some. The luxury It's not gonna happen. So this is just the schematic off the same, a shin and the pressure of the third opposing again. Now we're moving on to the blink. Reflex is again, As I said, difficult bit of a difficult You run out of me to remember all of these, but essentially have an Afrin from the trigeminal nerve from the cornea. It goes back to your trigeminal center in nucleus, and from the nucleus you have five is up arrived to the facial nucleus for the facial nerve. Uh, I have a site so on both sides, and those cause your eyes to closer. But that's a cotton wool, you touch the cornea, or you you can put some eyedrops A swell. You put some eye drops you so obviously the patient has closed eye. So you open the right slightly and you can touch with a quarter full. Or you can put some eye drops and you will still see the blink reflex. So just because you're pulling them slightly doesn't mean that the blink reflex is quite strong. So you will see the ice trying to blink if it's normal. So you do in either right. You take either right, and you take the response from I from either. Right. So the normal response is if you touch any cornea you have, bring a blink. Reflex is from both sides, and that's because it's trigeminal nerve gives. The reflex involves both facial nerves to cause the orbicularis Okay, light to close the eyes. So just teasing your brain's a little bit. Uh, with this case, you haven't unresponsive patient, a comatose patient, and they have the blink reflex is tested. Um, when his right corny, I stimulated you. You stay with the right cornea. He only close the right eye when you stimulate the left cornea the only place is the left eye. Where where do you think is the lesion? How would think? Don't worry too much, As I said, a bit of a complex and out of me, and it's, you know, it's with the first presentation. You know, if it's the first time when you see these things, schematics, don't worry. It takes a little bit of time to, you know, and obviously doing a bit of reading. But just in the approach today, So it's just things to be aware of. And then you can deepen your knowledge more with some person study a couple seconds more, Let's try to get there at least 10 responses. Excellent. Very good. Good. So, uh, right Facial live. So I'm just gonna say each one just to give you an idea why it might not be the answer. It might be the answer. So the right corneas stimulated. He closed the right eye. If you had the right facial now, he wouldn't be able to close the right eye. I mean, that's that's in an ideal scenario where you have, like, a full sort of impairment of the right facial, because that would cause the right eye to not be able to close and bilateral trigeminal never. So. If you have both protectiveness problematic, then you will. You will have any response because the stimulus from either cornea wouldn't arrive toe any sort of facial nuclear in order for the blink reflex where the midline posed. That's the correct answer, and we're going back to this, essentially. So if you see from every from the Tradjenta live, we have the fibers arriving to the left regional center in nucleus, and then you have five is going to the Ipsilateral facial nucleus and the contralateral. So from the left it goes to the left and the right facial nuclear's. So if you have an imagine that the same thing is happening from the other side. So you have some of that cuts that's in between cuts, these fibers that arrived from the one trigeminal nucleus to the other side. Then you won't. You won't have a response on the other side, so you touch the right cornea. The transitional, um, we're arrived to the sensor nucleus and the PSA lateral facial never and caused the eye too close. But because there's some problem, it will not drive to the other side, and the same thing will happen with the other side. And so, yes, so you have essentially just the response from the same side that you're touching again. It's schematic here, which I find very helpful. Sometimes you can, you know you can take a full of a of a sneak peek so you can always remember. Always you can do the tests you could not show, just write down and then think about it. It's not, it's not. You could do it as many times as you want, but if you're not sure, you can always sort of seek help us, we said. So when the other thing that we check in criminal examination is the opposition, the eye movements. It's always in the comatose spaces. Think about horizontal and vertical I movements. So in. If there is so just check, Where are the ice place? Are they moving together? Are they in the midline, or are they moved to our one side or the other? And are they doing any any movement? And are they sort of dysconjugate is the other question. So if you have contributed movements to one side horizontally, we'll get to that, but it could be because of a stroke or seizures, so it come because of a hemispheric problem or a pump type problem. But it means like there's a There's a structural problem that's happening in the brain, the some activity that's moving both eyes towards one side or the other side. Usually you you need to have them in a neutral position. If you don't want to cover an active sort of structural problem, you can have, um, it can be a lot of abnormal movements dipping below being ping pong. So these movements, I would suggest you this excuse. You can have a look at the somebody was on getting that. There's like free available video on YouTube. Um, and you can see examples of those, but essentially most of them. You can reflect some metabolic encephalopathy, PSA Oh, brains and, um so they're not extremely good at localizing If you have this congregate, if you have a skewed deviation that that suggests a brain stem lesion, so one I one level and the other eye on the vertical plane is on a different level. If you have both eyes pushing downwards or if they're looking downwards and in a very chronic position, that means that there is something pushing on the dose of brainstem. So the dose, um, mid brain lesion, like a pineal sort of tumor assist, or any any kind of a bleed that might be pushing on the brain stem on the top on the mid brain, pushing them, causing the ass to go down. And And if you have one, I down and out, so one I only that usually shows. And there posing that in the specific is it would be a third nipple shadow, Liza the general sort of patterns of Ulysses. So always remember horizontal and vertical planes. And again, it's important to know what you can see if you have deviations. Usually it's structural problem if you come up normal movements with sort of movements, with off the eyes going left and right, then that can also minimal the bullet problem. It's an important, like if you have so if you go, if you see someone who has the eyes, deviate to one side, that's, um, that's because that frontal I fields are affected or at what we call it a poem time horizontal, horizontal, congregate Games center control center is effective, so you have I control center in the frontal. I fields. It's frontal, I feel so that's something that's an error in the pre frontal lobes. So it's side pushes the eyes in a congregate gates congregate, meaning both together, sort of equally towards the other side. So if you have a destructive lesion, see if you destroy that part of the frontal lobe of the frontal, I feels because you have a tumor or a bead or a stroke there, then the other eye field is, um, sort of over activating. And you don't have opposed action from the destroyed one, so you will have a deviation off the off the ice towards that destroyed, um, destroyed the area. So if you have a stroke or a tumor, basically the eyes will look towards the stroke or the tumor. So that's an important thing to remember. That opposite, unfortunately, happens with, but obviously we have a a stroke on the right side, you will have a weakness on the left side. You have eyes deviated. The ice will look towards the stroke, but the weakness really opposite side. So that would be an important thing to remember if you have ah, a seizure now the seizure will affect the left side, but because you're not having destruction of the front like it's, but it's a shin, the eyes will push onto the opposite side view so the eyes will look away from a seizure. But towards a stroke, if it's in the frontal, I fields and forth. It gets a bit more complicated if you have, um, a pawn time a lesion. But for purposes off, um, sort of large strokes like Atlanta emcee a stroke which might cause of reduced constant. We have a movement to one side and weakness on the opposites. I think about a stroke or a tomb, a structural problem. The the next step, the next step in the crime. You'll notice this quite important, but obviously not very often performed is to check the vestibuloocular reflexes. So the Oakland A folic responses can be checked either with a head drop thrust maneuver. So you have the patient. This is only done if there's no trouble. See spine injuries. By the way, you don't try, but you have you you cracked open the rise. It's a bit complicated but complex that we try to open the rise and you move their head to one side and the other side very, very, with very brief movements, a very quick movement. And you see what their eyes are doing. And if their eyes so there. I should always move, um, to the opposite side of where you're turning the head. And that's the vestibular killer reflex. So if the if the eyes are set on the side of your moving the head to, then that means that the vestibule okay, reflex is impaired and we'll see what that means. This is not very sensitive. It's It's a very weak stimulus when you have common with patients and you, I don't need to do color call correct responses. I have never seen them happen, so it's a theoretical thing, but it's demanding in resource is and I'm and I've never seen it happen in the acute seven, um, again, very complex demotic. But essentially remember this. So this is all about horizontal I movements and horizontal head movements. Um, so the side of you of your head, too. Uh, the vestibular apparatus on that side will get activated and will give signals to that. It's a lot of a stimulant nuclear's. So if you turn your head to the right side for simplistic, you tell you here to the right side, the right side, the vestibular nucleus would like get activated. Um, Vestibuloocular reflex means that when that first initial is gets activated, gives signal to the opposite abdu since nucleus to turn the ice towards the opposite side. So when we have a an impact, vestibuloocular reflects, we move the hip to the right side and our eyes would move to the left side before coming back to do the usual side. But if you you have no movement towards the opposite side so that we have, like the doors eyes record them, so your eyes are fixed in the position that you change. That means that was to be looking at reflexes in Pat. Now there is a My personal experience with this is that if you're not confident in doing that and you know, coughing it, doing that with cook quick movements, then don't give too much. You know, don't try to interpret the results because if you move the heads slowly, the eyes are bound to be fixed that they will not move towards the opposite side. So I've seen it happen many times and misinterpretation off. Sort of. No, I movements were there was inside being labeled as vested local reflex problem and breaks. And probably it's all about that the speed of movement. So if you do it fast enough, you will see the opposite side, the eyes moving to the opposite side. Um, or but if you do it slowly, you will not, um, again ask you magic Bit difficult part of the examination. If you're not confident doing that, you can ask the neurologist, Do you have any step? Um, it's actually a normal looking for Okay, Like a panic reflex for the hepatitis maneuver. Said this. And intact this to the local reflex, if that's more so more more likely to have an impact brain stem. So it's quite useful if you can do it. But if you can't then citizen, you know, Miss, interpret the results. That was the most difficult part of the examination on then. Some other important part is the breathing patents. So the general concept is how does your patient breathe if you let them in the comatose state, Jamie Stokes. You have the you must have been familiar with it, but basically it's a small a small volume of breathing, followed by increasing volume of breathing and then again, smaller volume of breathing and then pause, sensitive before starting that again that cycle again. But it's not very helpful. Localizing can be seen in a lot of sort of medical problems, cardiological problems as well. But what has been found more recently is also that the other Parton's can be a bit more localizing. But generally they're very difficult to differentiate, and they're very difficult to assess, especially when the patient gets is already intubated. So I would say this. You make a note if you see anything strange. So if you see any accent breathing so breathing, that is all random, with the sort of inspiration expiration being out of sync or baking again, you know, being very strange. So make it and know that, but it's not. It's not necessarily going to show you some localization. And then we arrived. Look for examination, we said it's very limited examination. So, uh, you can only see what spontaneous movements there are and write down so if you see any purposeful movement. So if the person tries to do something on their own, so that means that they're not common, so they are in, developed a thick and they need to be worked up like that so there might be confused or in deep confusion on a hyperactive delirium. But they wouldn't be able to move and do purpose of movements if they have known purpose or so sort of pulling my chronic movements Problem. I clonus is sort of my chronic movements off the arms and legs in a random pattern that affecting the whole sort of body is usually caused by an oxy brain injury but also can be caused by some trucks. Ah, and the way you can assess the motor. The motor response. Basically, the the examination of the motor system is only by seeing what the response is. Do the pain, and you can only check the reflexes in the planters. That's that's pretty much what you can do. It's very important to do it on both sides. So, um, if you find in a cemetery, be careful because it might, it might cause it might bring on a suspicion of the coma, for example, of, ah, of a stroke, for example. Um, if you have, someone will talk a little bit about this. Uh, looked in syndrome a bit later on that I mentioned here, um, and again, the court again did the cerebral pushing again. Even though we do think that they have have localizing value with the red nucleus or below the red nucleus, it seems that the most recent resets shows, or at least of expert opinion, shows that it's not very much of localized body, but it does show sort of deeper levels of come. Um, and then you do your general physical examination. So it's It's like an extension of the history taking. So you try to do a general inspection. See, they are sort of neglected. Cachectic have any vitamin? The deficiencies. Are they? Is there any intravenous drug use elicit drug use science? Is that joint this? Is there any evidence of a sort of abnormal liver function? In a way, are there any abnormal strength smells that might suggest the ethanol or kept doses are they do their observations of this that they're in sepsis on. But that's the reason why they went on to a comatose state. Did they have any kind of rhythm? Is that they have any recent? A miser they was. Is the holes reason why they're they're in the state like that? Because they had a cardiac arrest recently, which they sort of, in a way, you know, the cardiac arrest, but a severe in mind that they recovered from, um or they're recovering from slowly on it. Is the temperature okay? Do they Do they have any science off infection anywhere or any signs off malignant? You're elected malignant syndrome or hypothyroidism for hyperthyroidism. And do they have any immunity? That's quite important for us neurologists. Do they just move their head? See there, If they're having any sort of free flex movements, which much it is, they have their CNS infection. Even this is my general suggestion is, especially at the F one level, for example, or an essential ever would be try to rule out the major catastrophe. So your sister, patient with unconsciousness all the world safe. For whatever reason, you're alone of it at the time. But usually you need to involve more senior doctors but politics. But try to answer these eight questions and you'll be able to do the best that you can do for that first assessment off sort of an unresponsive patient. So could this be a major anoxic? Oh, and scheme a consult of the brain so it could be a major stroke or a major, my cardiology, a fraction that lead to an anoxic injury to the brake. Could this be an intoxication? Very easy and smell. You can get the history from the collateral history suggest that would just be a CNS infection. Is there a recent flu like illness? Temperature minimizes, um, or seizures and confusion proceeding. What Whatever happened are the immuno suppressed, which might raise the suspicion of CNS infection. Good. This behind a blessing. No hyperglycemia. Very easy to dissect the glucose hyponatremia. You will have that on a B, D or VBG as soon as they arrive in in in the men's department. Could this be nonconvulsive status? Epilepticus. This is something that most people don't think about. But if there is a seizure activity preceding all that or a history of epilepsy or not well controlled epilepsy and the person is taking a long time to recover, then nonconvulsive status epileptic. So they are in a state off status, but it's not presenting itself with convulsions might be causing them to be in in a comatose state. So that will be assessed with an e g. Um, and could this be a numbers to the buzzer artery? Um ah, which can cause a coma and can become a struggle. But you can, you know you can save them and reverse the disability to an extent. If you thrombolysis example that you do the range where it's from back to me and the way to do that too. Consider that is, if you see brace them science essentially. And that's why it's so important examination and how quickly thinks came only they came on suddenly than the stroke is suggested. Basilar artery can be the culprit. Could be psychogenic. Um, essentially, I would mention a little bit about that, but psychogenic, um, again, it can be a often you. It's not gonna be very, very uncommon for psychogenic and unconsciously unresponsive is to get intubated, for example. But you will be looking for some positive psychogenic science, which I would imagine again so the next time. But have you done all of this is probably localized the lesion remembering the anatomy that I mentioned, remembering the potential ideological categories that we mentioned. So structure or certain more diffuse the folic problems and will go into a few cases for that. So you have a 42 year old man. He was brought in with a sudden onset, right sided, weakness and left MCP info was already diagnosed in the, um in school. He was struggling eyes and have is from back to me. But later in the day, the same day that he had all that after he recovered from the initial sort of state that he was in with the left, emceeing for he started dropping his consciousness level. So he initially had his eyes open. It was following instructions, and then he suddenly have his eyes closed, barely opening them, and he wasn't really sort of localizing. So we'll plan to rescanned him. But in the meantime, you also developed on this or Korea, so anything he didn't have that when she started being a bit less responsive. But then upon read reviews, so you remember where it was really review this patients were on well, he develops and it's a quarter while waiting for the CT scan, and he has a left sided, dilated and unresponsive like people. What do you think is the likely cause? So as we said, you know, obviously you see this, I want you, at least at the end of this presentation, to think unequal pupils a symmetry, it seems. Structural needs brain imaging. Now you want to think of it for that. So this person has a left dilated pupil and it's unresponsive to light. So, as we said, this is probably at problem with the third nipple F third never so depressing. Pathetic problem, Um, and thinking bit further on, let's see what your answer. Good. So So that's, um that's a very interesting, um, response, obviously post reliably the basic progression. That's the first thing that comes to mind, isn't it? Because some of symbolized they seem to be something seems to be pushing the third, and they might. That might be easily be. It bleeds. That's pressing again on the tentorium, pushing on, causing a hemispheric sort of uncle had nation and pushing on the third nap, causing all this situation in this general case. Is this the thing that nothing is ever what what you expected to be. He have, unfortunately, because it's a It's a true case. He had the unfortunate affair that reversing the bustle Africa. So I was the course, which is a symmetric people's. Obviously they they were few other signs that I didn't mention here. But it's a lesson to be learned is that you would you know, you could, uh, do a CT angiogram and find that, uh, second case in medicalization. So young epileptic admitted with three generalist medical excisions still drowsy one hour after the last seizure. If his disease is low, is ah is an eight. He's barely opened his eyes again, making some saying some words, but not really making any sense. And, uh, and he's not really localizing like he's moving his arms away from the paint. There are no movements, but his eyes are doing a conjugated but rithmetic directed movement towards up and right. So it was in a way that his eyes were moving like that, and this is what you have. So you called that greedy to assess the space in the procedures, uh, earlier. Then they're not having any obvious sort of clonic, or tonic movements, and they're very drowsy. You can sort of get them to open the rise a little bit, saying a few words, but they're seem to having this. And this is just again trying to suggest to you that, you know, whatever, whatever the reduce responses, it become a systematic approach. You wouldn't gonna miss that, right? If you just said, you know, you know, if you didn't examine thoroughly, you you might have missed the eye movements. But, um, you know, you could say it's a person's postictal noted for an examination, so, you know, give the plan and go away. But essentially, if you have a system, I think approach, you would pick up the eye movements. Let's see what you think. Well, so that's a very you know, That's very interesting because, uh, so some of your thinking that there might be an underlying brain lesion needs it and brings camp. Not necessarily. The patient is Ah has had, um, is known epileptic. There's a lot of history missing, so I'll give you that. So there's a lot of history missing from here. So are they taking the medications? They're on any other reason why they might have gone into this situation if they've never. If they didn't have a seizure for 10 years and never happened, then obviously we need the brain scalp. So we're not necessarily saying answers all right or wrong, obviously. But you have just a little bit of information that just a simple message get through to you is ongoing seizure activity, no jail and who's who can observe s. So that's one sort of approach ongoing, subjective give Benzodiazepines is the other approach, and this are clear cause to you request, um, step. So these are the difficult cases, very difficult cases where this person has seizures. So these are these are these are manifestation of seizures. What what has happened is the patient has had generalized tonic clonic seizures. The brain is basically, in a way time. Then your eyes are tired, and that's where they're not manifesting anatomical planet movement. So they have, in a way, in nonconvulsive status because their eyes are still moving in arithmetic way. So it's still suggested that they haven't seen So you getting some better? The other consent, they settle. The reason why I wouldn't observe is because they have lots of seizures, so they might be in a way in what we call it post status epilepticus nonconvulsive status epilepticus. So it's It's a bit of a complex one, but essentially you do a systematic approach. If that's something doesn't sit well with you. You speak with your senior. I will give them better. As a result, they settled. You need to give them mental there. It's essentially you can away. And the CT scan will definitely depend on a lot of more things in the history and the examination that we don't have available. So we've done what we can. So we take a history examination. Well, localized the lesion, if possible. Or we have an idea about where the lesion might be. So we think about the investigations now. Obviously, this is a non exhaustive list. So are you gonna be able to think about that straight away? If you have a a systematic rows of your history and examination, your investigations will come, um, need to come in in a step wise approach again. I would start off with some investigation very easily obtainable and could give a lot of information and then move on to more specialized investigations. So you obviously your history examination. Do your CT head scan. Practically everyone who is very unresponsive will require some kind of brain imaging in the city. It's going to pick up most of the things. Uh, do any CT. Make sure that there's a narcotic causes or any cardiac of normal. You are with me is, um, some basic blood tests and a cruise, the thyroid function tests and then a BG. So if you do these things, you will rule out most of the major causes metabolic causes off on unresponsive patient and pick a big sort of structure abnormalities or any heart abnormalities that might be causing that if you don't finances and you move on and you do more specialized that you try to arrange for an MRI scan. The MRI scan take practically and is useful in just a few sort of scenarios. Compared to this, a CT in the city so it can pick up high pox it brain injury more quickly. You can pick up strokes that are a bit cryptogenic so critical cryptogenic on s so they're bit more difficult to ah, pick up with a CT head scamp, so brings them strokes. So our little thalamic stroke convicted with the MRI and not with the city's cancer easily. You can pick up press or posterior reversible and cantaloupe with syndrome um, which can manifest with confusion. Incisions can lead to a comatose state, and it can also pick up sort of some obscure and capabilities. Easy can pick up no convulsive status, and the lumber country will pick up your sort of, if inflammatory or 10, you know, inflammatory or infectious poses for CNS infections as causes for your answer possible. If you've done all that and you still have the right to a result, then you just need to go back again. And you need to think about the history again and think about the examination again. So that's why I was saying that, you know, like it's a chain off events and sometimes you know people with unresponsiveness we will not get the answer straightaway. Might take a month. Might take a few weeks for us to get the answer because things will evolve very, very difficult to deal with. And careful it is my notes, you know, my note play all that counts from day one or two. So every step on this sort of way on the how the patient has been managed and how clearly things have been passed down from one team member to the other will play a significant role in their prognostication. So we move on to one. Okay, so with this important for my next point, we're approaching the end. So it is an important case and has a lot to to teach. I think it did me a lot. Um, so we have a 68 year old man. He has a one week history of deteriorating mobility over. So the history is that, you know, he has been moving less and less, you know, staying in bed more time, asked for the family he was referred to us was he was in the hospital because of reduced responsiveness. Um, and, um, this is getting gradually worse. So this is all you get you get the patient is not very responsive, so you need to get more history. But you need to assess in a swell. So you go to examine them and they open the rise and they move them up and down in the blink when you ask them. But he's not verbalizing, and he's not really able to track in there. He has no more to responsibility. There's no movement. So, uh, his reflexes are absent in his platins planters a minute. So what is the GCS? It's a bit difficult, obviously, Maybe five more seconds. All right, Good. We're divided again. So that's excellent. Yeah, it's, um it's a bit more difficult. So it's the difficulty with scales, isn't it? Because you this person is obviously has. They're open their eyes on instruction and they keep them open. Okay, so they kept them open. And I'm not trying to, you know, say what's right or wrong here, but if they say they keep their eyes open and keep the mobile, so I will give them a four for that, they're speaking. They're not speaking a pool, so give them one in. The motor response is a bit strange because they can follow instructions will give them a six, but from the other side, they're not moving a pill. So your records that would give him one. So what is the right answer would probably just use a descriptive term, So I would just say what is exactly happening because, for example, in patients who have a phase here, they will not be able to talk because they have a face is. So you just need to specify that it doesn't bring the GCS stop. It just says that you know there are facing. So in this case, as we will see, it's a bit more complicated. So where is the lesion in this same gentleman? So you can read again what is happening? So opens his eyes so the D rating ability reduce Responsiveness was suggested, but you go and see them and they are having their eyes open to move them up and down and the blink. But they're not verbalizing. They're not tracking and there's no motor response. They're not moving anything. And then the reflexes are absent and the plot planters a minute, so there's no plantar response and the reflexes are completely absent. Where would you place the lesion? Is it the left them say? Definitely one of the fellows. Any of the rest. It's a few seconds more, and we get to 10. I want to see how divided weather in the opinions no excellent, were divided. That's great. So left them safe territory. I would expect the person to just have, you know, right sided weakness. They wouldn't necessarily have the left side of the weakness that they seem to be completely weak everywhere. Not moving. So I just probably nothing the left them see as the first one. Calamos. Yes. How much would be a possibility? The difficulties with no motor response to pain. So they're not moving at all. So I wouldn't really be able to explain that very, very easily unless, um and then Oh, really? Are they really comatose? They have their eyes open. So kind of makes you think they are not very sort of responsive, but they don't have the right clothes, which you would expect in a sort of in a college. Stayed in the thalamus filament problem bilateral thalamic problem, for example. They can full instructions, but it just it just can't seem to follow all the instructions. So they were not able to move. There are eyes on the left and right, Um, and the the reflexes are absent, which is a bit strange, isn't it? Um, brace them. Yes. That was my first stop that the basilar artery thrombosis or the locked in syndrome, as we say. But why? The reflex is absent, and I'm not quite sure. Um, spinal cord. It would explain a lot of the things, but it wouldn't explain of the problems with being able to move eyes or follow structures as as easily these interruptions. A This man wasn't able to stick out your tongue will do anything else, which I didn't mention. Obviously, that was my mistake. Um, so this particle to explain a lot of the weakness. Um, perhaps not the absent reflexes, but in some occasions, yes, but not here. And I said, No, I'm putting peripheral nervous. Let's see, That's important world investigations. Would you consider in this case, them? What would you do? The patient has been in for perhaps a week on You've been asked to see them with this case, and, you know, you made up your mind. What? What do we give? The first thing the man has been is a plus or minus civil. You don't necessarily need to do the management, but, you know, just there's an investigation plus minus 10 minutes and then putting it here. Okay, More seconds. Right. Good very good. We're divided again to see someone. Some people have put the nerve conduction studies in the empty. So incredibly, this man have. Basically, it brings me to my next point. But this man had it view lumbar, a type of military type. Ah, problem which caused him to become very, extremely weak. You couldn't move, so he was locked in in a way, but not from a central call, but from a personal course. And because it came on very quickly and it was a bit, um he was a bit the his baseline was not very good. Essentially, it was, in a way, not missed, but it wasn't considered at the at the right time. So when when we assess him, you know, it was already here. He was already unable to move any of his limbs and that, you know, the hint of that is actually the completely absent reflexes. Would you? You know, would you think about that? So, you know, just the completely absent reflexes. We made a difference off. You know what we thought? The the problem was compared to, for example, of basilar artery that thrombus, which would have caused it, looked the classic locked in syndrome. So he was essentially able to move his eyes up and down and not do myself secret sort of blink and move his eyes up and down. So that's essentially locked in syndrome. But the interesting thing was the cause of that, um and um, brings me to the point of think about the coma mimics eso. Locked in syndrome is a common mimic. The difference is that person is completely aware but unfortunately, unable to move their arms legs or do any movements of the, ah, mouth or tongue. So it's a It's a basilar from both cysts in the ventral points, and the only thing usually the person can do is perhaps blink and move their eyes up and down. It's really horrible. And if if you have a systematic approach, you know gonna miss it so you can you can give him through the life so you can do from back to me and you can offer them the best chance. So it's it's really catastrophic for someone, isn't it? Because they're completely aware of what's happening. But they can't, um I kinetic um, UTIs, um is a similar case to what we described an aggressive GBS Um Ah, or a very rapid in your original degenerated condition. Like prime can, you know, cause you to be in a state where you can you're not really moving or you usually have your eyes open and that difference or you have your eyes open and it's the way things have progressed. It really will see other clinical science. Obviously you see my plunders, perhaps, or absent reflexes. In other cases in DBS Severe Capital mia, that has to be some kind of psychiatric background on functional psychogenic unresponsiveness. So if you have no no political attacks surrounding this, you do that you have dropped test is probably 100 s. You raise the element. You know, you just let it go usually just a fall on top of the head. If it falls, you know, conveniently away, then it's unlikely to be an organic sort of comatose state. You you can take Aleve. No staff haven't done it myself. But if they have like resisting, I open. If they're resisting the eye opening, for example, that's that. That's a clear sign of a functional, understands it and tried to bring these positive science in order to make a confident diagnosis rather than say, but always sometimes can be very, very, very difficult. So we have done all what we can do, investigate. And we have thought about the mimics. So what do we do to manage things? So you have done your CBC Be very early on, and you have corrected most of the things you have considered an election we mentioned. That usually doesn't cause any harm, especially if you have no brain stem signs. The pupils are a bit sort of pinpoint. There's some kind of history of opioids. Give them a little bit a small dose of from the looks. Um, they might recover. I've had someone who came in a stroke. Oh, no, not long ago. And they actually have opiate Texas. The accidental opiate toxicity on. And they have, you know, the they're pupils were not that pinpoint as well. But you get a small amount of, um, election. They came back completely fine. And you have you have been you have the chance to read all the major metabolic electrolyte abnormalities. And if there is a mass lesion you obviously discussed with the neurosurgical team and try to do the man's with the increased ICP. They will probably give you the question How to do that. It's outside the scope again and again. You give them seeing this infection very early. Only be if you consider it if there's a special you given the antimicrobials and you include the cycle. Where in that, um, just remember that unresponsive is a symptom, not a condition. So you need to find the course. We're so you treat the cause. And then how about prognosis? Just a few words here, Essentially home. Um um, if in a way, if the cause is not lifted or if it's a persistent course with this and there's support for a period of time, there are some possible outcomes from this room and the person My If this, the theory is that might become bring death, they they might awaken and have persistent vegetative state. Or it might come back to a degree of consciousness with variable sort of states, like the minimal conscious state, very disabled but conscious state, and you can also have a good recovery. So these are the potential sort of outcomes. It's very much based on what the cause is how long it stays there and what kind of support has been offered. In the meantime, there are some predictive, but they have mostly used for anoxic brain injury after cardiac arrest. Again, it's a bit outside of the scope. Usually it's certainly neurologist to deal with. But there are some predictors of how things might have old, um, and the the minimally consciously that the persistent vegetative state are the some of the states. The two states of the person might come out off if they're not, if they don't recover and they don't become brain dead and they have some mild effect. So these are the states, um, where the person is not really communicate with the environment on DA. They might have a return of the sleep wake cycle that they didn't have during the coma, but they they're minimally some communicative. In the minimally competences contra state. You might have a bit more responsiveness in the sense that they might say simple words, even or might do simple instructions, but and that in good ways is better than the PVs. But again, not a very good outcome again bring the having its ugly outside the scope of this presentation, but it is a clinical sort of diagnosis. Usually we do use some simplemente investigators usually click a clinical diagnosis. Just remember that this is in a new rice use for a situation where everything reversible needs to be ruled out first. Before we arrived to that conclusion, I think I will mention anything more here because other things of any benefit to you at this stage potentially arriving cool. My conclusion. So go is a talented presentation, usually and unwell patient. So so you need to have a careful approach to them, and they're successful management. A better outcome relies on the chain off events that happens, and you need to be a good, strong length of the same. I can't stress that enough. When you assess, use this systematic approach or any systematic approach it you might find more usual in your career steps. But ask yourself these eight questions that we said they're eight red flags in manage all the easily reversible and serious causes, which might cause deterioration of the know dealt in quickly. Your investigation should be done in a stepwise fashion, so don't drive to the MRI scan as a first step without sort of ruling out the other easy things first. But obviously there can be, you know, that's that's not written stuff on prognostication again will require all the steps to be. Ideally, all the steps have been that have been taken will give the best chances up the best prognosis. And if not, then at least will be aware of what the cause is for about prognosis. What the cause is, um so, yeah. So, uh, you have any questions? So, uh, just answer my screen. This is the your link to the feedback and the certificate. Um, perhaps we share it. Also in the he resented that the, uh, the job, it would be helpful.