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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.
Progress Test-Type Questions: Question 1 | Question 2 | Question 3Applied 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
- 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 level of consciousness
- 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
- 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 level of consciousness
- 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
- Advance care planning
- Death and dying
- Breaking bad news and conveying prognostic information to family/whānau
- Advance directives
Hauora Māori
- Communication with whānau
- 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
- 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
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
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
hydrocephalus, myxoedema coma, hypo/hypernatraemia, Addison's disease, suicide attempt
