20 Neurological examination Determine level of consciousness byGCS
21 * The Glasgow Coma Scale is used to determine the severity of a brain injury. It is often used at the emergency scene or emergency room.* The scale is used as part of the initial evaluation of a patient, but does not assist in making the diagnosis the cause of coma* Motor, verbal, and eye responses are rated.
31 INVESTIGATION Drugs screen(eg_salicylates- -diazepam-narcotics-amphetamines)-Routine biochemistry (urea-electrolytes-glucose-calcium-liver biochemistry)-Metabolic and endocrine studies (TSH-serum cortisol)- Blood culturessuch as cerebral malaria(thick blood film)-If the explanation remains unclear ,further investigation are needed .
32 IMAGINGCT or MRI brain imaging may indicate an otherwise unsuspected mass lesion or intracranial hemorrhage.
33 CSF examinationLumber puncture should be performed in coma only after careful risk assessment .it is usually contraindicated when an intracranial mass lesion is a possibility .CT is necessary to exclude this. CSF examination is likely to alter therapy only if undiagnosed meningoencephalitis or other identifiable infection is present .
38 GIVE 50% GLUCOSE 50ML INTRAVENOUSLY IMMEDIATE MANAGEMENTGIVE 50% GLUCOSE 50ML INTRAVENOUSLY* THE RISK OF PERMANENT BRAIN DAMAGE IN THE HYPOGLYCEMIC PATIENT OUTWEIGHS THETEMPORARY WORSENING DUE TO INDUCED HYPERGLYCAEMIC STATE.* ABSENCE OF HYPOGLYCAEMIA SYMPTOMS DOES NOT EXCLUDE HYPOGLYCAEMIA.* HYPOGLYCAEMIA AT ‘NORMOGLYCAEMIC LEVEL’ IN DIABETIC PATIENTS.38
39 Restore the hydration by IV fluids. IMMEDIATE MANAGEMENTRestore the hydration by IV fluids.Treat the hyperthermia/ hypothermiahyperthermia is more danger than hypothermia39
40 TREAT RAISED INTRACRANIAL PRESSURE SPECIFIC THERAPYLOOK FOR ANY SEIZURE ACTIVITY (signs can be subtle like just twitching of mouth and eyes)GIVE DIAZEPAM 10mg IV SLOWLY FOLLOWED BY PHENYTOIN 15mg/Kg 50mg/minTREAT RAISED INTRACRANIAL PRESSUREHYPERVENTILATION (PaCO mm. Hg) %MANNITOL (1.5 to 2.0G/Kg) FRUSEMIDE 40 to 120mg IV DEXAMETHASONE 12 to 18mg IV40
41 IF SUSPECT MENINGITIS/ ENCEPHALITIS SPECIFIC THERAPYIF SUSPECT MENINGITIS/ ENCEPHALITISSTART ANTIBIOTICS (3rd generation cephalosporin) IV ACYCLOVIR IV 10mg/Kg. 8 hourly for HSE QUINIDINE IV for strong suspicion of cerebral malariaRESTORE THE ACID-BASE BALANCEMETABOLIC ACIDOSIS – cardiac abnormalityMETABOLIC ALKALOSIS – respiratory depressionRESPIRATORY ACIDOSIS - presages respiratory failureRESPIRATORY ALKALOSIS – cardiac arrhythmias41
42 SEMI-PRONE TRENDELERG – ONE MOMENT PLEASE…POSITION OF THE PATIENTSEMI-PRONE TRENDELERG –post-ictal state, drowning, metabolic causesELEVATION OF HEAD END TO 300 IN SUPINEraised intracranial pressure due to any causeELEVATION OF THE LEG ENDcirculatory failureCATHETER THE URINARY BLADDER42