Coma Hot Case

OVERVIEW

  • approach to the coma hot case for the FCICM exam

GENERAL APPROACH

Structural – focal

  • Abscess
  • CVA
  • Trauma
  • Bleed – SAH, ICH
  • Surgery
  • Hydrocephalus
  • Seizures

Non-structural – global

  • Meningism – SAH, meningitis
  • No meningism – metabolic, electrolytes, sepsis/seizures, organ failures, toxins (MESOT)

INTRODUCTION

  • always introduce yourself to the patient – even if he/she appears unconscious

CUBICLE

  • dialysis (uraemia or accumulation of sedatives)

INFUSIONS

  • nimodipine or Mg2+ for SAH
  • noradrenaline to maintain organ perfusion or CPP

VENTILATOR

  • level of support (high level shows patient still critically unwell)

MONITOR

  • temperature
  • ICP monitor

EQUIPMENT

  • EVD (SAH, TBI, blood stained, infected)
  • ICP

QUESTION SPECIFIC EXAMINATION

  • neurological

-> head (surgery, drains)
-> paralysed (pupils, TOF)
-> unconscious (GCS, neck stiffness, agitation and cause, brainstem reflexes, tone, reflexes)

  • hands -> head -> chest -> abdo -> feet -> back

-> cardiovascular
-> respiratory
-> abdominal

  • recent sedation and paralysis
  • other sedating medications

RELEVANT INVESTIGATIONS

  • ABG
  • microbiology: sputum, blood cultures, CSF
  • electrolytes
  • liver and renal failure
  • recent CT

OPENING STATEMENT

= “Multi-factorial”

  • Categorise into structural and non-structural OR intracranial and extra-cranial
  • List headings of causes -> clinical signs associated with list

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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