✅ کما
توی مبحث قبلی درباره سنکوپ که نوعی (TLOC) بود صحبت کردیم، حالا میخوایم درباره coma صحبت کنیم. محاوره ای یعنی بیماری که بیهوش شده.
هرکی بیهوش شد آوردنش اورژانس بهش نالوکسان بزنیم؟ قند چی؟ و... .


Coma is defined as "unarousable unresponsiveness".

📝ED order for LOC
#Order

▪️Imp: LOC
▪️Cond: Emergency
▪️Diet: NPO
▪️Pos: CBR and sides up, Stabilize cervical spine(as needed)

▪️CVS q1h
▪️IV line fix

▪️oxygen therapy with nasal cannula or mask
* to maintain sat 94-97%

▪️Intubate if GCS ≤8

▪️Stabilize cervical spine

▪️IV fluid therapy as needed
*treat hypotension (mean arterial blood pressure [BP] of < 70 mmHg) with volume
expanders or vasopressors or both .

▪️Check CBC, glucose, Na, K, Ca, Mg, P, BUN, creatinine, PT, PTT, ABG, LFTs, drug screen

▫️other lab tests: blood cultures, adrenal and thyroid tests, coagulation tests, carboxyhemoglobin, specific drug concentrations.
* according to level of suspicion for diagnosis or if cause remains obscure

▪️ ECG stat

▪️Foley and I/O chart

▪️consider appropriate radiography as needed (in trauma)

▪️Head CT
* It should be performed in most patients, except when there is an obvious, reversible, nonstructural explanation for impaired consciousness (eg, the prompt recovery of consciousness after naloxone administration in cases of opiate intoxication or after glucose administration for hypoglycemia)
* prioritize emergent if focal neurologic signs, papilledema, fever.

▪️Consider LP as needed
* prioritize emergent after CT scan if fever, elevated WBC, meningismus; otherwise do according to level of suspicion for diagnosis or if cause remains obscure.

▪️ Consider EEG if indicated
* for possible nonconvulsive seizure, or if diagnosis remains obscure.

▪️Brain MRI with DWI if indicated
* if cause remains obscure

▪️Amp Glucose 50% IV 50 mL
*after blood drawn, before results back

▪️Amp Thiamine 100 mg IV

▪️Amp labetalol 5 to 20 mg IV boluses and repeated as needed(if indicated)
* in severe hypertension (MAP > 130 mmHg),

▪️Amp Acetaminophen 1gr IV (if indicated)
* in Hyperthermia (T > 38.5°C)

▪️Treat definite seizures with phenytoin or equivalent:

▫️Amp phenytoin (20 mg/kg IV; do not exceed 1 mg/kg per minute; maximum rate: 50 mg per minute) diluted in N. S.
e.g Amp Phenytoin 20mg/kg at 300 cc N/S in 30 minutes
*Both fosphenytoin and phenytoin require cardiac and BP monitoring.
* فنی تویین نباید در سرم قندی انفوزیون شود
or
▫️Amp diazepam 10mg IV (max rate 5mg/min)

🔹Consider empiric treatments

▪️For possible infection:
▫️Amp Ceftriaxone 1g IV stat
▫️Amp vancomycin 1g IV stat
▫️Amp Acyclovir 10-15 mg/kg Iv stat

▪️For possible ingestion:
▫️Amp Naloxone 0.4-2 mg slow IV stat(suspected opioid toxicity)
▫️Flumazenil 0.5 mg/5ml if indicated
▫️consider Gastric lavage/activated charcoal(50g or 1g/kg) if indicated.

▪️For possible increased ICP:
▫️Amp Mannitol 1g/kg IV over 30-60 min.

▪️For possible nonconvulsive status:
▫️Amp diazepam 10mg standby

▪️consider ICU admission and intubation

➡️ Coma and stupor