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Unexplained loss of consciousness

Clinical Discipline(s)/Organ System(s)
Cardiology, Cardiovascular System, Emergency Medicine, Nervous System, Neurology, Respiratory Medicine, Respiratory System
Progress Test Topic(s)
Cardiovascular, Neurological
Description
An 87 year old NZ European woman is brought to the Emergency Department by ambulance. She is unconscious and was found on the floor by a cleaner. You have no other history.
Applied Science for Medicine 
   - Anatomy of the skull and brain; structures responsible for maintaining consciousness
   - Physiology and regulation of the central nervous system (CNS) environment; function of the reticular activating system
   - Physiological response to raised intracranial pressure
   - Circulation of cerebrospinal fluid (CSF) and control of CSF volume
   - Aetiology of cerebral hypoperfusion
   - Pharmacology of opioids, benzodiazepines, alcohol, flumazenil, fibrinolytics, inhalation anaesthetic agents, thiopental, muscle relaxants, carbamazepine, sodium valproate, phenytoin, gabapentin, lamotrigine, ethosuximide and phenobarbital
Clinical and Communication Skills 
   - Elicit a collateral history from the emergency medical services, family/whānau, others
   - Perform an assessment of the level of consciousness using Glasgow Coma Scale (GCS) and Alert, Voice, Pain, Unresponsive (AVPU) Scale
   - Perform an assessment of airway, breathing and circulation; recognise signs of life; signs compatible with brainstem death
   - Examination of the unconscious patient; recognise neurological findings in raised intracranial pressure and signs of base of skull fracture
   - Perform a venepuncture, blood glucose level, venous cannulation, arterial blood gas, ECG, lumbar puncture
   - Differential diagnosis of reduced GCS
   - Interpret full blood count, blood glucose level, arterial blood gas, pathology report on CSF, ECG, chest X-ray
   - Indications for CT Head, MRI brain, CT angiogram, MR angiogram, electroencephalogram, brainstem testing, transjugular intrahepatic portosystemic shunt (TIPS) procedure
   - Management and complications of reduced GCS
   - Management of a cerebrovascular accident including the use of thrombolysis, warfarin/dabigatran toxicity
   - Management of hypoglycaemia, status epilepticus, raised intracranial pressure
   - Risk factors and management of rhabdomyolysis
Personal and Professional Skills 
   - Advance care planning
   - Death and dying
   - Breaking bad news and conveying prognostic information to family/whānau
   - Advance directives
Hauora Māori 
   - Communication with whānau
Population Health 
   - Present and future age structure of New Zealand population
   - Projections for life expectancy and years lived with disability
   - Residential care: present needs, future requirements
Conditions to be considered relating to this scenario
Common
cerebrovascular accident, overdose, warfarin toxicity, side-effects of medication, gastrointestinal bleed, anaemia, encephalitis, meningitis, pulmonary embolism, hypoglycaemia, epilepsy, shock (hypovolaemic, distributive, cardiogenic), diabetic ketoacidosis, hyperosmolar non-ketotic syndrome
Less common but 'important not to miss'
massive haemorrhage, cardiac arrhythmias, subarachnoid haemorrhage, diffuse axonal injury, raised intracranial pressure, severe acidosis/alkalosis, CO2 narcosis, extradural haemorrhage, subdural haemorrhage, carotid artery dissection, uraemic encephalopathy, hepatic encephalopathy
Uncommon
hydrocephalus, myxoedema coma, hypo/hypernatraemia, Addison's disease, suicide attempt