حالات الاستقبال ج5

#

Coma



(disturbed level of conscious)




...

Signs of lateralization:

deviation of the angle of the mouth.

Deviation of the tongue.

.Weakness on one side with withdrawal on painful stimulus

Change in the tone on one side.

Eye deviation

Babiniski (extensor planter response)



Causes: A-With lateralizing signs: ( need CT





1CVS (stroke): cerebral hge or infarction( thrombus or

embolism)
2Hypoglycemia





B-Without lateralizing signs: (mostly metabolic causes
hypertensive encephalopathy



Chronic liver ds (LCF) >>>if he came with lateralizing signs, do CT



Chr. renal failure



Resp. failure



Hypoglycemia



DKA



Severe electrolyte disturbance



CNS infection e.g. encephalitis or meningitis



Other causes of DLC:



Drugs & toxins



Hysterical



Space occupying lesion e.g. abscess or brain tumor



N.B.: Hypoglycemic coma & coma due to HTN encephalopathy are not essentially associated with lateralizing signs.





Management:



Rapid history



of DM ( hemotest, urine for sugar & acetone



Of HTN



Of alcohol intake



Of drug abuse >>>> Antidote
Of any systemic ds





VD

BP >>>>> HTN encephalopathy

Temp. >>>>> fever for e.g. meningitis, encephalitis, chest infection

Pulse
RR >>>>> resp. distress due to RF e.g. COPD



Examine for signs of lateralization



Metabolic profiles



ABG , ECG , X- ray chest , CT brain



Cerebrovascular stroke (CVS)





The hallmark is abrupt onset of symptoms & neurological deficits
e.g. weakness, deviation of angle of mouth, tongue, convulsions, incontinence, coma



Risk factors

Ask rapidly about DM, HTN, old age, smoking, heart ds.

(AF>> embolism)



valve replacement, collagen ds >> vasculitis, obesity

1st Aid:
VD: BP, pulse,



History





Examination

if DM >>> hemotest, urine for sugar & acetone.

, CXR, ECG.

PT, PTT if AF or recurrent stroke.

Ryle for feeding if chocking.

Catheterization.

CT scan

.
Value of CT scan white>>> hge, black>>> infarction)



It demonstrates: - Cerebral hge (from the 1st moment): consult
neurosurgery





- Cerebral infarction: if free follow up CT should be done
after 48hrs





- Space occupying lesion >>> CT with contrast, MRI: consult
neurosurgery



- Brain edema>>> sulci & gyri are not clear



TTT of stroke:





ttt of risk factors:
HTN >>> BP should be reduced gradually (not more than 140/90 to maintain cerebral perfusion), DM, Ht ds, hyperlipidemia...





Brain dehydrating measures

To treat brain edema around area of hge or infarction.

Mannitol followed by lasix

If # as in renal failure or ht failure >>> give Decadron or Glycerin

Pt on Mannitol should follow serum creatinine
Nootropil ( neuroprotective) 2amp /6hr





Care of comatosed pt

Frequent change of position in bed.

Ryle for feeding.

Catheter
Regularly check: urine output, DVT, Bed sores, auscultate chest…





Anticoagulants in case of infarction:
Indications

: - Valve replacement

- AF



- Dilated cardiomyopathy

- Stroke in evolution

- Post circulation stroke
- Recurrent stroke



#

: - Recent surgery

- Malignant HTN



- Bl. Tendency
- Inf. endocarditis except if the pt with valve replacement.



Dose:
Heparin 5000IU IV/ 4hr >>>follow up with PT


Antiplatlet (Aspocid) (Trental) in case of infarction



Epanotin is given in case of IC hge to inhibit fits especially in lesions near cortex.