Approach to the Dx of the comatose pts

After stabilizing the pts →

First objective - dDx the cause of the impairment:

1. Structural? (due to a focal injury along the course of the RAS pathways) - Px, CT, MRI;

2. Metabolic? (diffused process) - Hx, Px, Labs;

Hx (from Relatives, Friends, or Attendants)

• Onset of coma (abrupt -✓in young: drugs, SAH, trauma. In old: ICH, infarction; gradual - ✓ metabolic)

• Recent complaints (focal weakness, vertigo, headache - ✓ compressive lesions; depression - ✓intoxication)

• Recent injury

• Previous medical illnesses - diabetes, renal failure:✓ metabolic disorders; heart disease: ✓ infarction;

• Previous psychiatric Hx - ✓ intoxication

• Access to drugs (sedatives, psychotropic drugs)

General Physical Examination

• Vital signs

• Evidence of trauma - Bilateral black eyes, Battle’s sign → ✓ basal skull fracture;

• Evidence of acute or chronic systemic illness Evidence of drug ingestion (needle marks, alcohol on breath)

• Nuchal rigidity (assuming that cervical trauma has been excluded)

The key components of the Px

1. Determent the level of consciousness of the pts,

2. Determent the pattern of breathing - (Pathologic breathing patterns = level of lesion),

3. the size and reactivity of the pupils,

4. the eye movements and oculovestibular responses

5. the skeletal motor responses.