Delayed Emergence 

 

 

Differential Diagnosis ("DIMS") 

 

  • Drugs 

    • Anesthesia related:

      • Sedatives & narcotics 

      • Residual paralysis, pseudocholinesterase deficiency 

      • Drug error

    • Non-anesthesia related:

      • Street drugs, alcohol 

      • Herbal medicines (valerian root, St. John's wort) 

  • Infection:

    • Encephalitis, meningitis

    • Sepsis

  • Metabolic:

    • Hypoxia

    • Hypercarbia

    • Electrolyte abnormalities

    • Hypoglycemia or hyperglycemia (DKA or HONK)

    • Hypothermia

    • Uremia

    • Hepatic encephalopathy

    • Osmolality problems

    • Myxedema coma

  • Structural:

    • Stroke (ischemic or hemorrhagic) 

    • Hydrocephalus

    • Diffuse anoxic injury

    • Cerebral edema

    • Seizure or post-ictal

    • Pneumocephalus

    • Cerebral hyperperfusion syndrome (post carotid endarterectomy) 

 

 

Management 

 

  • Scan monitors: HR, ECG, rhythm, EtCO2, SpO2, BP, temp

  • Ensure stability of ABC's

  • Confirm reversal of paralysis

  • Review all drugs administered & syringes for drug error

  • Focused physical exam:

    • Neurological: GCS, pupils, gag/cough, symmetric motor movement, focal signs

    • Cardiorespiratory: adequacy of perfusion

  • Blood work:

    • CBC, lytes, urea, creatinine, glucometer, osmolality, ABG with lactate & ionized calcium

    • Liver enzymes, bilirubin

    • Toxicology screen

    • TSH, FT4

  • Consider: Neurology / ICU consultation, CT head, EEG, lumbar puncture

  • Empiric therapy:

    • Glucose: 25-50 cc of D50 or 250 cc of D10

    • Thiamine 100 mg IV

    • Opioid reversal: naloxone 0.04 mg IV q 2 mins, up to 2mg

    • Benzodiazepine reversal: flumazenil 0.2-1 mg IV q 1 min, up to 1mg

    • Physostigmine (0.5 to 1 mg IV) counteracts but does not reverse sedation caused by inhalation anesthetics, other sedatives, & anticholinergics

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