Brain imaging is indicated in patients with new focal deficits. Many patients just need more time and waiting before ordering tests is often the right decision-and the most cost-effective-when careful history and physical examination have not raised red flags. ![]() Meanwhile, splinter hemorrhages in the conjunctivas or nail beds can be the clue to the diagnosis of fat embolism in patients who fail to arouse after the repair of a long bone fracture.Īdditional testing should also be focused and directed by the findings on physical examination. For instance, in the very early postoperative phase, close attention to the depth and pattern of respiration is crucial and should alert us to the possibility of CO 2 narcosis. The value of a detailed general physical examination should not be forgotten. Rigidity and clonus should call attention to the possibility of drug toxicity (more on this later) asterixis can be the clue to hyperammonemia or other metabolic disturbances myoclonus can be seen with various toxic and metabolic encephalopathies, but also after severe brain anoxia. Subtle nystagmus-like movements of the eyes or slight twitching in the face or fingers may be the only clinical expression of underlying status epilepticus. Presence of lateralizing signs (e.g., asymmetric response to pain) demand consideration for brain imaging. The neurologic examination should be focused on assessing the level of consciousness, brainstem reflexes, gaze, muscle tone, responses to pain, and presence of adventitious movements in the eyes, face, or limbs. Adequacy of oxygenation, deviation from expected hemodynamic parameters during surgery, blood loss, and difficulties with hemostasis are pieces of information important to acquire. Adequate history-taking in these cases should include a detailed review of the preoperative, intraoperative, and postoperative records as well as communication with the anesthesiologist and the surgeon. Stroke, global cerebral anoxia/ischemia, and status epilepticus need to be considered among the many other causes that can be responsible for the persistently impaired consciousness ( table 1).Ĭareful history and neurologic examination are essential to reach the correct diagnosis and it is a frequent mistake to miss important information because the history is not readily available from an interview and the examination is deemed limited and confounded. However, the main role of the consulting neurologist in these instances is to exclude primary neurologic disease. 1 Prolonged effects of anesthesia, particularly when combined with sedative effects of other medications (such as opiates) administered during and after surgery and in patients with liver or renal dysfunction, can explain some of these cases, as illustrated by vignette 1. CT scan shows massive brain edema.įailure to awaken after a surgery performed under general anesthesia is a common reason for urgent neurologic consultation in the hospital. Examination shows coma with bilaterally nonreactive, midposition pupils, preservation of corneal reflex only on one side, and no motor responses to pain. ![]() ![]() A 68-year-old man is comatose after an ablation procedure for ventricular tachycardia complicated by refractory cardiogenic shock.
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