RAMB - Julho 2016

urrent

clinical

approach

patients

with

disorders

consciousness

ssoc

ras

2016; 62(4):377-384

383

FIGURE 1

Algorithm of the initial approach to the patient in a coma.

BP: blood pressure; GCS: Glasgow Coma Scale; MAP: mean arterial pressure; HMG-CoA: 3-hydroxy-3-methyl-glutaryl coenzyme A; GOT: glutamic-oxaloacetic transaminase; GPT: glutamate-pyru-

vate transaminase; CT: computed tomography; CNS: central nervous system; CSF: cerebrospinal fluid; MRI: magnetic resonance imaging; EEG: electroencephalogram.

Yes

Normal

Specific

treatment

Specific

treatment

Thiamine 100 mg IV +

glucose 50%

50 mL if Dx < 60 mg/dL

Naloxone 0.4 to 2 mg IV

every 3 minutes if narcotic

poisoning is suspected

Flumazenil 0.2 mg max 1 mg

IV if poisoning by

benzodiazepines is

suspected

Gastric lavage with activated

charcoal if drug intoxication

is suspected

Intubation if GCS ≤ 8,

maintain SaO

> 90% and

MAP > 70 mmHg

Coma

Assessment of air ways, BP, pulse,

temperature, capillary blood glucose

Intravenous access and monitoring

Laboratory tests: HMG, Na, K, Ca, Cl, GOT,

GPT, blood gas and toxicological screening

Quick history

Brief general and neurological examination

Specific toxic-

metabolic

assessment

Thyroid hormones

Serum cortisol

Consider brain MRI,

CSF and EEG

Medical history and complete physical

examination

Head CT if structural damage or CNS

infection is suspected

CSF

Focal signs and

abnormal head

CT findings

Neurological and/or

neurosurgical

assessment

History of meningitis,

fever or meningeal

irritation

No focal signs

Normal head CT

scan

Meningitis

Evident

toxic-metabolic

cause?

that could be essential for localization and etiology of the

patient’s symptoms. Basic laboratory investigations and

imaging tests are of utmost importance for differential

diagnosis.

The prognosis is extremely variable and depends on

the cause, duration and extent of the affected site. How-

ever, effective initial care and introduction of proper treat-

ment are crucial in order to prevent the occurrence of sec-

ondary damage and to speed up patient recovery.

esumo

Abordagem clínica atual do paciente com distúrbios de

consciência