----- Original Message -----
From: "Dunn Matthew Dr."
Subject: Re: Taxing case 1 third instalment/ coma case.
> Certainly one option. Burr hole may be life saving. On the other hand it
may
> delay definitive neurosurgical treatment and may be fatal in itself (how
> confident are you that you can deal with a major bleed from the meningeal
> vessels.
Agreed!
> You're assuming that the patient is coning, presumably on the basis of
> obliteration of one lateral ventricle and bradycardia. No pupillary
> abnormality has been noted and there was no evidence of raised
intracranial
> pressure on fundoscopy. These are pointers but insufficient to make the
> diagnosis in themselves (I've seen patients with obliteration of one
> ventricle with little disturbance of conscious level; there are a lot of
> other causes of bradycardia). Remains a bit of a judgement call. At the
very
> least I'd have another good look at the fundi and pupils before I got my
> knife out.
Now, I really think you are being a bit too "physicianly" if you don't think
this is coning, Matt! They didn't get a chance to recheck the pupils on the
way to scan, and the fundi were never checked, and aren't much use at
diagnosing coning in any case, or acutely raised ICP for that matter.
Looking for other causes of bradycardia, when you've got this patient with
this scan in front of you, is bordering on the ridiculous (in my opinion).
At least if we do call ourselves "emergency" physicians, then we should
respond in this manner!
AF
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