16Abnormal breathing Occurs shortly after the heart stops in up to 40% of cardiac arrestsDescribed as barely, heavy, noisy or gasping breathingRecognise as a sign of cardiac arrest
17Circulation - C Pulse Arterial Pressure Rate Rhytme Hypertension Hypotension
18Disability - DDisability is determined from the patient level of consciousness according to the AVPU or GCS.A for ALERTV for VOICEP for PAINU for UNRESPONSIVE to any stimulus
19GLASGOW COMA SCALEI. Motor Response 6 - Obeys commands fully 5 - Localizes to noxious stimuli 4 - Withdraws from noxious stimuli 3 - Abnormal flexion, i.e. decorticate posturing 2 - Extensor response, i.e. decerebrate posturing 1 - No responseII. Verbal Response Alert and Oriented Confused, yet coherent, speech Inappropriate words and jumbled phrases consisting of words Incomprehensible sounds No soundsIII. Eye Opening Spontaneous eye opening Eyes open to speech Eyes open to pain No eye opening
20Exposure an Environment - E The patient’s clothes should be removed or cut in an appropriate manner so that any injuries can be seen.
28 Evolution of neurologic signs in coma from a hemispheric mass lesion as the brain becomes functionally impaired in a rostral caudal manner. Early and late diencephalic levels are levels of dysfunction just above (early) and just below (late) the thalamus.
32The eye examinationPupillary abnormality is one of the cardinal features differentiating surgical disorders from medical disorders. Pupillary abnormalities in coma generally herald structural changes in brain, whereas in metabolic coma such abnormalities are not present.
41Laboratory examination Chemical blood determinations are made routinely to investigate metabolic, toxic or drug induced encephalopaties.ElectrolytesCalciumBlood urea nitrogenGlucoseNH3
42Laboratory examination Toxicological analysis is of great value in any case of coma where the diagnosis is not immediately clear.The presence of alcohol does not ensure that alcohol is the cause of the altered mental status. Other, life-threatening, causes must be ruled out.
43Imaging In coma of unknown etiology, CT or MRI must be performed. Radiologically detectable causes of coma;HemorrhageTumorHydrocephalus
46Electroencephalography EEG is useful in unrecognized seizures.
47Lumbar punctureThe use of LP in coma is limited to diagnoses of meningitis and instances of suspected subarachnoid hemorrhage in which the CT is normal.
48Complaints Diagnosis Action History of diabetes, use of oral anti-diabetic or ingestion of alcohol* Hypoglycaemia• *Test blood for glucose using test strip or glucose meter. • Give IV GlucoseHistory of ingestion of medication (tablets or liquid). There may be smell of alcohol or other substance on breathDrug overdose. e.g. Alcohol,• Support respiration • IV Glucose to prevent hypoglycaemia. In chronic alcoholics • Precede IV glucose with IV Thiamine, IV fluid administration.E.g. Paracetamol.• Gastric lavage, n- acetylcysteine treatment if > 140 mg/kg body weight ingested
49Complaints Diagnosis Action Presence or absence of history of diabetes; - polyuria, polydipsia - hyperventilation - gradual onset of illness - evidence of infection - Urine sugar and ketone positive - Blood glucose> 250 mg/dL* Diabetic ketoacidosis• *Give Soluble Insulin and Sodium Chloride 0.9% infusionFever, fits, headache, neck stiffness, altered consciousness etc* Meningitis or Cerebral Malaria• *Treat with antibiotics and quinine until either diagnosis confirmed.History of previous fits, sudden onset of convulsions; with or without incontinence.* Epilepsy• *Give Diazepam, IV, to abort fits and continue or start with anti-epileptic drug treatment
50Complaints Diagnosis Action Patient with hypertension or diabetes; sudden onset of paralysis of one side of body.* Stroke• Check blood pressure and blood glucose.Patient with hypertension, headaches, seizures* Hypertensive encephalopathy• Check blood pressure • If very high, give oral or parenteral anti-hypertensives