Day # 132 - Decreased Level of Consciousness

Today we talked about a patient with decreased level of consciousness. We initially discussed the differential causes. I have previously blogged about this here.

This case turned out to be a deliberate ingestion of benzodiazepines. The management of benzodiazepine overdose can be approached as follows:

1. Supportive care: protect the airway (accessory devices like nasal or oral airways, intubation if necessary), support the breathing (supplimental O2, positive pressure ventillation if required), support the circulation (IV fluids, pressors etc)
2. Consider decontamination with activated charcoal (usually not done, can cause vomitting and aspiration which would comprimise your airway and of best use within 1 hour of ingestion)
3. Consider specific antidote (flumazenil) -- but use with caution as it can precipitate withdrawl (including seizure) in patients who are chronic users and can exacerbate other toxicities (i.e. tricyclics)
   
4. Look for co-ingestions (ASA, tylenol, opiates, alcohols, tricyclics, etc..)
5. Involve your friends from psychiatry in deliberate ingestions
   

This article discusses the relationship between burden of illness and suicide in the elderly. Elderly men are one of the highest risk groups for completing suicide attempts.

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Neurological examination of the comatose patient.

Remember you can still do the following:

• Cranial nerve reflexes
  
  • Pupils
  • Corneal
    
  • Dolls-Eyes
  • Caloric ear stimulation
  • Gag reflex
• Motor
  
  • Ellicit movement with noxious stimuli
  • Evaluate tone, bulk, reflexes, babinsky
• Sensory
  
  • Ellicit response with central and peripheral noxious stimuli