NCCEd: Neurocritical Care Education for Residents

For a patient who is comatose, guidelines recommend monitoring for 24-48 hours. (You could alternatively get a 1-hour recording and calculate a 2HELPS2B score to stratify their risk for having seizures based on what is recorded in that one hour epoch, though it's not a perfect tool, so it's reasonable to err on the side of recording longer as originally suggested.)

It's important to specifically identify what tests you want to order. Your poor junior resident may not know what "just send the usual tests" means. No test is perfect, so you do need to have some reasonable suspicion if you're going to look, as you don't want to fall for any false positives. For this patient, the basic studies of cell count and differential, protein, glucose, and Gram stain and culture are a good start. You'll almost never be faulted for sending HSV PCR though.

But, we did mention that there are a few additional organisms we're worried about-- namely more atypical ones. We're not worried about VZV, but if we were, it could be helpful to send both the PCR as well as serologies (though they may not have seroconverted). In an immunosuppressed patient, fungal serologies and CrAg are good to check. The patient doesn't have any risk factors for TB, so you defer AFB testing.

One thing we glazed over was not a lab test, but a measurement. Opening pressure. Is that something that could be helpful here? Now that you think about it, it could be helpful to know if it's high, as we do suspect some sort of meningoencephalitis. Could an elevated opening pressure also somehow be tied with his fixed and dilated pupils?