Thursday, September 1, 2016

ED Approach To The Comatose Patient

Author: Trinquero P - Edited by: Alkawham L - Expert Commentary: Fant A
Citation: [Peer-Reviewed, Web Publication] Trinquero P, Alkawham L (2016, August 30). The ED Approach To The Comatose Patient [NUEM Blog. Expert Commentary By Fant A]. Retrieved from
Coma is a fairly common problem encountered in emergency departments (EDs) across the country. Approximately 3% of all ED patients arrive in some sort of altered mental state. The differential diagnosis is broad, but initial evaluation should center on treating any reversible causes and attempting to differentiate a structural brain lesion from a more systemic toxicity. Approximately 85% of altered mental status cases are caused by metabolic or systemic derangements. Structural lesions cause 15% of cases..
  • Consciousness is the combination of arousal and cognition. Arousal is synonymous with awareness, both of self and surroundings. Cognition is the combination of orientation, judgment, and memory.
  • In order to be awake, aware of our surroundings, and fully oriented, we require intact cerebral cortices and an intact RAS. A fully comatose state implies dysfunction either in both cerebral cortices or dysfunction of the brainstem where the ascending RAS fibers originate.
  • The overarching goal of the physical examination of a comatose patient is first to treat any reversible causes and then to attempt to differentiate a structural lesion causing localizing neurologic findings from a more systemic disturbance.
  • A careful examination and strategic laboratory testing as proposed above can help to guide further testing and management by narrowing down the differential diagnosis
  • Always consider toxic ingestion on the differential diagnosis and strive to obtain collateral information to assist your work up"