COMA

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Approach to comatose patient
Definitions

Alert (Conscious) - Appearance of wakefulness, awareness
of the self and environment
 Lethargy - mild reduction in alertness

Obtundation - moderate reduction in alertness. Increased
response time to stimuli.

Stupor - Deep sleep, patient can be aroused only by
vigorous and repetitive stimulation. Returns to deep sleep
when not continually stimulated.

Coma (Unconscious) - Sleep like appearance and
behaviorally unresponsive to all external stimuli
(Unarousable unresponsiveness, eyes closed)
Psychogenic unresponsiveness
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The patient, although apparently unconscious,
usually shows some response to external stimuli
Eyes: fixed stare and has quick blink.
An attempt to elicit the corneal reflex may cause a
vigorous contraction of the orbicularis oculi
Marked resistance to passive movement of the
limbs may be present.
Normal Vital signs and signs of organic disease are
absent .
Vegetative state
Patients who survive coma do not remain in
this state for > 2–3 weeks, but develop a
persistent unresponsive state in which sleep–
wake cycles return.
 After severe brain injury, the brainstem
function returns with sleep–wake cycles, eye
opening in response to verbal stimuli, and
normal respiratory control.

Locked in syndrome
Patient is awake and alert, but unable to
move or speak.
 Pontine lesions affect lateral eye movement
and motor control
 Lesions often spare vertical eye movements
and blinking.

Confusional state

Major defect: lack of attention
 Disorientation
 Patient
to time > place > person
thinks less clearly and more slowly
 Memory
faulty (difficulty in repeating
numbers (digit span)

Misinterpretation of external stimuli
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Drowsiness may alternate with hyper excitability and irritability
Delirium
 Markedly
abnormal mental state
 Severe
confusional state
 PLUS Visual hallucinations &/or
delusions
(complex systematized dream like state)
Coma Etiology
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1.
2.
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Primary CNS Structural lesions
Supratentorial (bilateral cerebral hemispheres affected)
Infratentorial (brainstem affected)
Diffuse CNS dysfunction due to
Metabolic-Toxic causes.
Metabolic cause of Coma

Respiratory
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Hypoxia
Hypercarbia
Electrolyte
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Hypoglycemia
Hyponatremia
Hypercalcemia
Hepatic
encephalopathy
 Severe renal failure
 Infectious
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Meningitis
malaria
Encephalitis
Toxins, drugs
Primary CNS structural cause of Coma
Supratentorial
 Hematoma
 Neoplasm
 Abscess
 Contusion
 Vascular Accidents
 Diffuse Axonal
Damage
Infratentorial
 Vascular accidents
 Neoplasma
 Trauma
 Cerebellar hemorrhage
 Demyelinating disease
 Central pontine
myelinolysis (rapid
correction of
hyponatremia)
Pneumonic for possible causes of COMA
TIPS and AEIOU

Trauma/Temperature
 Infection (CNS or other)
 Poisoning/Psychiatric
 Space occupying lesions/Stroke
 Alcohol/Acidosis
 Epilepsy/Endocrine
 Insulin(hypoglycemia/hyperglycemia)
 Oxygen(Hypoxia)
 Uremia
Approach to comatose patient in ED
General examination:
On arrival to ER immediate attention to:
1. Airway/Breathing
2. Circulation
3. establishing IV access
4. Blood should be withdrawn: estimation of
glucose, other biochemical parameters,
drug screening
COMA-Initial assessment
History:
 Abrupt onset suggest CNS
Hemorrhage/Ischemia Severity or Cardiac
ethiology.
 Progression over hours/days suggests
progressive CNS lesions or metabolic-toxic
causes
All possible information from:
Relatives, Ambulance personnel and from
Bystanders
COMA-Initial assessment cont……
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Previous medical history:
1.
Comorbities, DM,HTN, Alcohol and Drug abuse,
Epilepsy
2.
Mental health history
Clues obtained from the patient's
1.
Clothing or
2.
Handbag
Careful examination for
1.
Trauma requires complete exposure and ‘log roll’ to
examine the back
2.
Needle marks
COMA-Initial assessment cont……
 If
head trauma is suspected, the
examination must await adequate
stabilization of the neck.
 Glasgow Coma Scale: the severity of
coma is essential for subsequent
management.
Head and neck
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1.
2.
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The head
Evidence of injury
Skull should be palpated for depressed
fractures.
The ears and nose: haemorrhage and
leakage of CSF
The fundi: papilloedema or subhyaloid or
retinal haemorrhages
Neck : stiffness
Raccoon or Panda eyes a sign of basal skull fracture
Glasgow Coma Scale
Not useful for diagnosis but used to follow patient’s course and
determine if improving or deteriorating
ITEM
SCORE
Eye Opening
Sum = GCS (range 3 to 15)
Spontaneous
4
To speech
3
To pain
2
None
1
Best Motor Response
Obeys commands
6
Localizes to touch
5
Withdraws to pain
4
Abnormal flexion
3
Abnormal extension
2
None
1
Best Verbal Response
Oriented (Person, Place, Time)
5
Confused
4
Inappropriate words
3
Incomprehensible sounds
2
None
1
Glasgow Coma Scale
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The score is expressed in the form "GCS 9
= E2 V4 M3 at 07:35
Generally, comas are classified as:
 Severe, with GCS ≤ 8 –Need intubation
 Moderate, GCS 9 - 12
 Minor, GCS ≥ 13.
COMA-Initial assessment cont……
Temperature
Hypothermia

Hypopituitarism, Hypothyroidism
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Chlorpromazine
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Exposure to low temperature environments, cold-water
immersion
Risk of hypothermia in the elderly with inadequately
heated rooms, exacerbated by immobility.
COMA-Initial assessment cont……
Hyperthermia (febrile Coma)
 Infective: Malaria, Encephalitis, Meningitis
 Vascular: pontine, subarachnoid hge
 Metabolic: thyrotoxic, Addisonian crisis
 Toxic: belladonna,ectasy abuse,salicylate
poisoning,neuroleptic malignant syndrome.
 Sun stroke, heat stroke
 Coma with 2ry infection: UTI, pneumonia, bed
sores.
COMA-Initial assessment cont……
Pulse
Bradycardia: brain tumors, opiates,
myxedema.
 Tachycardia: hyperthyroidism, uremia

Blood Pressure
High: Hypertensive encephalopathy
 Low: Addisonian crisis, alcohol, barbiturate
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COMA-Initial assessment cont……
Skin
Injuries, Bruises: Traumatic causes
 Dry Skin: DKA, Atropine
 Moist skin: Hypoglycemic coma
 Cherry-red: CO poisoning
 Needle marks: drug addiction
 Rashes: meningitis, endocarditis
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COMA-Initial assessment cont……
Pupils
Size, inequality, reaction to a bright light.
 An important general rule: most metabolic
encephalopathies give small pupils with
preserved light reflex.
 Structural lesions are more commonly
associated with pupillary asymmetry and
with loss of light reflex.

COMA-Initial assessment cont……
Odour of breath
Acetone: DKA
 Fetor Hepaticus: in hepatic coma
 Urineferous odour: in uremic coma
 Alcohol odour: in alcohol intoxication
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COMA-Initial assessment cont……
Respiration
 Cheyne–Stokes respiration:
(hyperpnoea alternates with apneas) often seen
with cerebral disease and acidosis.
 Apneustic breathing
a pause at full inspiration –brainstem/pons
 Ataxic:
irregular respiration with random deep and shallow
breaths - Medullary lesions:
Signs of lateralization
Unequal pupils
 Deviation of the eyes to one side
 Facial asymmetry
 Turning of the head to one side
 Unilateral hypo-hypertonia
 Asymmetric deep reflexes
 Unilateral extensor plantar response (Babinski)
 Unilateral focal or Jacksonian fits
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Diagnostic testing in Coma
The goal is to identify treatable
conditions(infections, metabolic, drug
intoxication and surgical lesions).
 CT brain if papilledema or focal
neurological deficit.
 Urgent lumbar puncture if fever
suggesting meningitis or encephalitis.
Diagnostic testing in Coma
ABG
 Blood glucose, Troponin
 Blood film for Malaria
 CBC, LFT, Serum osmolality
 Urea &electrolytes
 Urine Analysis
 Creatinine, INR, PT,PTT
 ECG, CXR,EEG
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Management of the Acutely
Comatose Patient
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Airway, Breathing, Intubate if GCS <8 or possible respiratory
arrest
Management of shock. Do not use hypotonic solutions to treat
shock, particularly patients with coma or possible cerebral edema
Convulsions should be controlled
gastric aspiration and lavage for drugs and toxins
Fever control
The bladder should not be permitted to become distended
Management of Electrolytes (Na, K, etc)
Avoid aspiration pneumonia
DVT prophylaxis
Regular conjunctival lubrication and oral cleansing should be
instituted.
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