They can be out cold due to several reasons and they refuse to tell you what’s wrong with them.
How can you quickly find the cause of their altered mental status? What key aspects should you address in your initial assessment? What about gastric lavage? Antidotes? Do you always need a CT? What pre-test probabilities exist for different causes and what findings in your initial assessment have strong likelihood ratios?
In this talk from Karolinska’s GULD series, Jonathan Ilicki offers a structured and evidence-based framework for assessing the unconscious patient. It covers topics such as:
why mnemonics like HUSK MIDAS and AEIOU-TIPS can be bad
how to avoid naloxone-induced pulmonary edema
how age, blood pressure and neuro findings can help you identify the cause of altered mental status
when one should consider gastric lavage
and much more
The lecture’s in Swedish and has English subtitles.
Forsberg S, Höjer J, Ludwigs U, Nyström H. Metabolic vs structural coma in the ED–an observational study. Am J Emerg Med 2012; 30: 1986–90. [PubMed]
Forsberg S, Höjer J, Ludwigs U. Prognosis in patients presenting with non-traumatic coma. J Emerg Med 2012; 42: 249–53. [PubMed]
Ikeda M, Matsunaga T, Irabu N, Yoshida S. Using vital signs to diagnose impaired consciousness: cross sectional observational study. BMJ 2002; 325: 800. [PubMed]
Penninga E, Graudal N, Ladekarl M, Jürgens G. Adverse Events Associated with Flumazenil Treatment for the Management of Suspected Benzodiazepine Intoxication–A Systematic Review with Meta-Analyses of Randomised Trials. Basic Clin Pharmacol Toxicol 2016; 118: 37–44. [PubMed]
Ngo A, Anthony C, Samuel M, Wong E, Ponampalam R. Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department? Resuscitation 2007; 74: 27–37. [PubMed]
Singh P, Richell-Herren K. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Flumazenil and suspected benzodiazepine overdose. J Accid Emerg Med 2000; 17: 214. [PubMed]
Haverkos G, DiSalvo R, Imhoff T. Fatal seizures after flumazenil administration in a patient with mixed overdose. Ann Pharmacother 1994; 28: 1347–9. [PubMed]
Benson B, Hoppu K, Troutman W, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila) 2013; 51: 140–6. [PubMed]
Westergaard B, Hoegberg L, Groenlykke T. Adherence to international recommendations for gastric lavage in medical drug poisonings in Denmark 2007-2010. Clin Toxicol (Phila) 2012; 50: 129–35. [PubMed]
Yoshino T, Meguro S, Soeda Y, Itoh A, Kawai T, Itoh H. A case of hypoglycemic hemiparesis and literature review. Ups J Med Sci 2012; 117: 347–51. [PubMed]
Ohshita T, Imamura E, Nomura E, Wakabayashi S, Kajikawa H, Matsumoto M. Hypoglycemia with focal neurological signs as stroke mimic: Clinical and neuroradiological characteristics. J Neurol Sci 2015; 353: 98–101. [PubMed]
Luo S, Michler K, Johnston P, Macfarlane P. A comparison of commonly used QT correction formulae: the effect of heart rate on the QTc of normal ECGs. J Electrocardiol 2004; 37 Suppl: 81–90. [PubMed]
Glimåker M, Johansson B, Bell M, et al. Early lumbar puncture in adult bacterial meningitis–rationale for revised guidelines. Scand J Infect Dis 2013; 45: 657–63. [PubMed]
Ninio J, Stevens K. Variations on the Hermann grid: an extinction illusion. Perception 2000; 29: 1209–17. [PubMed]
Medical doctor and clinical innovation fellow passionate about Emergency Medicine and the intersection of science, EBM and technology. Currently leading medical innovation and development at a Scandinavian healthtech company.