Coma

ABCs
Airway – talking, swallowing?
Breathing – ventilation and oxygenation – mentation and O2 saturation.  Examine breathing pattern (Kussmaul, Cheyne-Stokes)
Circulation – peripheral circulation, feel pulses, capillary refill
VITALS
LOC – GCS

* Best Eye Response. (4)

  • 1. No eye opening.
  • 2. Eye opening to pain.
  • 3. Eye opening to verbal command.
  • 4. Eyes open spontaneously.

* Best Verbal Response. (5)

  • 1. No verbal response
  • 2. Incomprehensible sounds.
  • 3. Inappropriate words.
  • 4. Confused
  • 5. Orientated



 

* Best Motor Response. (6)

  • 1. No motor response.
  • 2. Extension to pain.
  • 3. Flexion to pain.
  • 4. Withdrawal from pain.
  • 5. Localising pain.
  • 6. Obeys Commands.

IF 8 OR LESS INTUBATE!!!!

HEENT:  Battle sign (basal skull fracture), rhinorrhea, otorrhea, neck stiffness

CN exam:

  • II
    • acuity: blink to visual threat;
    • pupils: size, reactivity;
    • fundoscopy: papilledema and hemorrhage
  • III,IV,VI
    • gaze deviation (conjuage – ipsilateral hemisphere, contralateral pontine)
    • Doll’as eyes (oculocephalic reflex) afferent 8, efferent 3,6
    • Oculovestibular (COWS, caloric reflex)
    • Corneal reflex afferent V1, efferent 7
    • Gag reflec CN 9,10
    • Jaw jerk CN 7

Reflexes – DTR, Plantar, Primative (glabellar, palmomental)
Motor exam – spontaneous movement, symmetry, purpose, tone, power, rxn to noxious stimuli
RAS or bihemispheric insult is required to lose consciousness

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