经过Neha Dangayach

Case vignette

Our patient, let’s call him Mr. KM is a 35 year old with PMH of hypertension who presented with acute onset of confusion, dysarthria and severe headache. While waiting in the ED triage bay he became suddenly unresponsive. The ED team rapidly assessed him, called a stroke code and intubated him. They found the following on their exam right before intubation:

生命力：非侵入性袖口的血压200/110，HR 100，窦性心动过速，afebrile

Focused Exam: Pupils anisocoria: Right pupil 4 mm and Left 2 mm and both sluggishly reactive

On painful stimulus, he was extending bilateral upper extremities and was triple flexing bilateral lower extremities. His tone in all extremities was increased. His airway was secured using theEMCrit NeuroCritical Care airwayparadigm And he received mannitol 1 gm/kg bolus and a liter of isolyte post-mannitol. He was hyperventilated, head was positioned at 30 degrees and maintained in the midline.

差速器目前包括：由于出现的大型容器闭塞（ELVO）引起的中风，可能是基底膜的基底凝块或椎骨解剖；亚蛛网膜下腔出血（SAH），高血压脑内出血（ICH）。插管后他开始使用丙泊酚滴水，但考虑到ELVO的关注，他的血压并没有降低。ED居民将Nicardipine带到CT扫描仪，以防他们发现流血。当患者被放在运输监测仪上时，他还被静脉注射的静脉注射60毫克/千克预防，并涵盖了任何可能引起癫痫发作的可能原因。

How to do a focused neurological exam in a comatose patient?

在欧洲重症监护医学学会（ESICM）的一份出色的专家小组报告中，关于危重患者的神经检查检查，关于如何进行专注的神经学检查，执行频率以及如何发展系统性的有几个关键建议利用这种考试进行及时诊断和管理的方法。

While the following steps aren't all exhaustive, these should be considered as practical steps for doing a focused exam in any patient with suspected coma and customize your exam based on the clinical scenario. The IBCC post on Stupor and Coma describes these steps in much more detail along with the anatomical basis for some of the reflexes etc.

First, make sure that you are able to stop any sedative and analgesic drips safely. If you’re in the ICU, always update the bedside nurse that you’re going to stop sedation to do a wake-up exam. Depending upon the agents being used, cumulative dosing, presence or absence of any underlying hepato-renal dysfunction, you can estimate how long it’ll take for a patient to wake up. For the type of patient who slips into a coma acutely in your ED like Mr. KM; you can jump right into a focused exam. So, once you have waited at least 10-15 minutes and see some signs suggestive of the patient waking up, start your exam with head in the midline, eyes in the midline, uncover the arms and legs and place the arms in the midline.

At every step of this exam, check what response you get and be systematic. Some of these elements of the exam will help you determine an objective score such as GCS (Glasgow Coma Score) or FOUR score.

Score their LOC (Level of Consciousness)

首先，喊出他们的名字。如果没有反应，那就抓住它们的肩膀（这相当于深度触摸），如果没有反应会给他们带来痛苦的刺激。疼痛刺激的一些例子包括胸骨摩擦，眶上压力，指甲床压力。观察眼睛，脸，四肢。GCS有其局限性，但我认为实用性在于对昏迷的客观评估。GCS 8或更少是昏迷的。昏迷，即缺乏意识和唤醒。对于每个响应，请注意眼睛，电动机，口头评分。这确立了您的基线。（对于KM先生。我们的GCS是E 1（无引人注目的），M2（上肢的伸肌姿势）V1（无语言响应）= 4（图1）

图1 a。https://www.mdcalc.com/glasgow-coma-scale-score-gcs

图1B。https://www.mdcalc.com/four-furl-unline-unresponsise-core

Arousal

作为您对唤醒的评估的一部分，如果他们有目光开头，请评估您的患者是否有目光的偏好，凝视偏差等。他们是否有视觉跟踪，即他们的眼睛在房间里跟随您。评估唤醒后，然后继续评估命令以下。如果他们没有睁开眼睛，包括疼痛在内的任何刺激，请确保您睁开眼睛并评估目光的偏好，凝视偏差等。

以下命令

Typically, you want to start with axial commands followed by appendicular commands. Axial commands e.g. Open and Close your eyes, Stick your tongue out. Appendicular commands: Eg. Show we two fingers, give me a thumbs up, wiggle your toes.

实用提示：对于通常在非主导半球病变患者中通常会看到眼睑失用的患者，您必须睁开眼睛以评估唤醒。挤压我的手，这不是一个好命令

Don’t forget to restart sedation or analgesia as needed. Use the right dose, right agent and analgosedation first and titrate to appropriate goals. In cases of suspected ICP, use both sedation (E.g. Propofol) and analgesia (e.g. Fentanyl) (Ref:PADIS guidelines）

脑干反射

至少，除了学生之外，还要检查以下内容：双侧角膜的咳嗽，如果没有可疑的宫颈绳损伤，请检查洋娃娃的眼睛反射或前庭 - 眼反射。对于角膜的反射，我建议您使用一点无菌水或盐水或Q-TIP（如果容易获得），并且在评估后不要忘记擦拭眼睛。当您检查洋娃娃时，除了存在或不存在外，还要检查眼睛处于主要目光位置（是否存在偏差，偏好等），还要寻找任何异常响应，垂直运动，眼球震颤等。

实用提示：如果您的病人很容易引起人们的注意，那么您可以跳过角膜。在检查洋娃娃的眼睛之前，请检查眼睛在主要凝视位置的位置。

目光的偏好与强迫凝视偏差：了解目光偏好之间的差异（当您引起娃娃的眼睛反应时可以克服），而不是被娃娃无法克服的凝视偏差。强制凝视偏差通常会暗示癫痫发作。

Tone, deep tendon reflexes, plantars

我通常会检查音调，即在各个末端对运动的被动抵抗。除非我认为这会为我提供一些增量信息，否则我通常不会检查所有患者的深肌腱反射。值得一提的是，在一侧或两个前进的脚趾或两种脚趾的脚趾或两种脚趾上都可以为您提供诊断线的诊断线索，这值得引起足底反应。

一个人应该如何发展昏迷的差异？

这些是我在开发昏迷的鉴别诊断时使用的原则：

Parallel process-is there something structural, electrographic or iatrogenic that can explain this patient’s coma. Or is it a combination of different causes, in which case, what is the primary driver?

因此，一旦获得ABC，我将确保我们快速指示，并让团队成员协调统计扫描。扫描的选择将取决于差异以及患者的稳定性以及他们可以忍受平坦的稳定性。例如，对于像KM先生这样的患者，我想进行最快的扫描，以便我们可以激活其他团队，例如神经外科，神经内血管等。取决于我们在扫描中诊断的内容。因此，就像ED团队一样，我将获得一个CTH/CTA的头部和颈部。如果您的中心能够在与CT相比的类似时间范围内进行MRI大脑，那么您也可以选择MRI/MRA中风协议。However for Mr. KM I am worried about his pupillary anisocoria, it’s telling me that he’s going to need an emergent intervention, he probably has raised ICP and I don’t think I want him laying flat in the MRI scanner for even a few additional minutes.

Practical Tips: Y你可以完成你的病人怀疑升高ICP by giving them a dose of hypertonics (mannitol or a hypertonic saline bolus) before laying them flat for a scan. Make sure your transport team keeps the head of bed up to 30-45 degrees throughout transportation and that you hyperventilate them either using a BVM or the transport ventilator. Don’t wait to get scans based on laboratory results…Parallel process.

Seizure Prophylaxis:除了寻找结构性原因,since there will be some delays in getting any patient connected to continuous EEG monitoring, it might be worthwhile loading them with an anti-seizure medication till we have more diagnostic certainty.

Recheck pupils：插管后并接受麻痹后，我们知道我们的患者的学生不应变得无反应，但它们会在各种骨骼肌中失去运动反应。插管后立即进行，在您移动患者进行任何扫描之前，请重新检查学生并治疗饲养的ICP，如果学生变得不反应或弧菌病恶化。

You can utilize quantitative pupillometry and/or optic nerve sheath diameter (ONSD) to assess response to your therapies as you get the patient ready for scans.

Be systematic：昏迷有很多不同的原因，IBCC的以下数字非常适合组织您的差异并进行初始检查。

实用提示 - 我通常会根据临床背景获得血管成像。我确实认为，如果您要扫描患者，无论是CT还是MRI，请稍作局面，并考虑是否要为任何差异差进行船只成像。您不想继续将重症患者送回扫描仪进行其他成像，并确保您可以及时激活血管内套件，因为一如既往，时间就是大脑！

Engage timely help: At every step of the way ask yourself, can I narrow my differential down and which other team do I need to engage. For Mr. KM on the non-contrast CTH we see high grade SAH, he has global cerebral edema and severe hydrocephalus. His CTA shows a fusiform left posterior inferior cerebellar artery (PICA) aneurysm. And as soon the ED resident sees the non-contrast CTH, she asks the radiology tech to pause and starts the nicardipine drip for SBP goal 100-140 mm Hg and cycles the blood pressure cuff q5 minutes till the blood pressure is within range. While the radiology tech is running the CTA, the stroke resident notifies the neurosurgery and Neuroendovascular teams on call regarding the need for emergent EVD and for activating the endovascular suite. The ED resident notifies the Neurocritical Care team about the need for an ICU bed. Mr. Kim’s right pupil isn’t reacting after he comes out of CT and the ED resident institutes all ICP precautions and gives a 250 cc bolus of 3% via the peripheral iv line.

This kind of parallel processing leads to excellent teamwork and prepares our teams and patients for success.

Mr. KM was rapidly taken up to the Neuro-ICU for an EVD placement. His pupils returned but he remained in a coma. He underwent an angiogram and coiling of his aneurysm. The placement of his EVD was confirmed via a dynamic CTH performed in the endovascular suite saving him another trip to the CT scanner. Post coiling his EVD was lowered to 10 cm above head level from 20 cm but he didn't wake up on post bleed day 0 (the first day of symptom onset or the first day for SAH patients). Since his exam didn't improve he was connected to continuous EEG monitoring. No seizures were identified on his EEG and his Keppra was continued for seizure prophylaxis for 7 days as per institutional protocol. He woke up and started following simple commands on post bleed 2 as his hydrocephalus continued to improve.

图2.非对比度CTH显示厚蛛网膜下腔出血，全球脑水肿和脑积水。

附加的代理资源beplay sports

• IBCC昏迷章
• EMCrit 186 – Coma with Eelco Wijdicks