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, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

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

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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