Peilin Lu
Neurology Department SRRSH

A 32 year-old woman is found on the floor at
work, unconscious, but spontaneously
breathing. In the ER, BP is 146/75, pulse 80,
afebrile. Her left pupil is 5 mm and
sluggishly reacts to light; the right pupil is 2
mm and briskly reacts to light. She does not
grimace or move to painful stimuli, nor
attempt to speak.

What is the problem?

What can I do to make diagnosis?

How to check and treat?
•
Coma
•
•
•
appears to be asleep
and incapable of being aroused by external stimuli
or inner need
serious disturbance of consciousness.
•
Disturbance of consciousness
•
waking disorder (Arousal disorder),
Drowsiness,
 Lethargy
 Coma




•
Light coma
Moderate coma
Deep coma
conscious content disturbance
Drowsiness is the lightest kind of disturbance of
consciousness,
 continuous pathological sleep state,
 patients can be woke up by mild stimulation
and correctly answer questions or make various
responses,
 but go back to sleep soon after stimulation
stopping.

•
•
•
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disturbance of conscious status whose
awakening level is more severe than drowsiness，
may show a short awakening after strong or
repetitive stimulation,
having no response or incorrect response to
language,
falling into lethargy very soon once the
stimulation is stopped.
•
•
•
•
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a kind of severe disturbance of consciousness
appears to be asleep
incapable of being aroused by external stimuli or inner need
patients can not recognize themselves or the surrounding
environment,
no eyes open movement and spontaneous language
movement,
rare spontaneous limb movement
physiological reflex
•
•
normal, reduced or lost,
vital signs can be stable or unstable.
Light coma
pain
stimulatio simple response
n
Many reflexes are
normal, such as
corneal reflex, cough
reflexes
reflex, swallowing
reflex and tendon
reflex,
Moderate coma
Deep coma
no response
no response
could exist but were
obviously weakened，
Tendon hyperreflexia
pathologic reflexes are
positive
No reflexes，
no tendon reflex
no pathological
reflex，Tetraplegia,
vital signs stable
could be normal
others
completely tetraplegia,
unstable
eyeball fixation,
mydriasis,
over-coma.
 irreversible brain damage
 loss of whole brain function,
 The termination of the cerebral circulation
 The dysfunctional nervous system which can
not maintain the stability of the body
environment

•
Confusion
•
mainly characterized by serious thought disorder,
may be accompanied with disorientation,
hallucinations, paranoia, anxiety, and so on.
•
•
Also known as acute mental disorder state,
Appears as poor performance of arousal level,
disorientation, lax attention, and serious
disorders of many aspects such as perception,
intelligence, emotion, and so on.
A serious disturbance of consciousness
 complete loss of perception, thought, emotion,
memory, will and language activities,
 No response to external stimulation and no limb
spontaneous activities

•
Stupor
•
severely impaired arousal with some responsiveness
to vigorous stimuli
•
•
•
•
•
•
•
Common in hysteria or after severe mental trauma,
Patients lose their response to external stimulation
suddenly,
May accompanied with fast breathing or breath holding,
Their eyes are closed or blinking rapidly,
Pupil light reflex are more sensitive,
Limbs are straight, buckling,
Neurological examination has no positive sign.

Locked-in syndrome

the losing of all other movement functions except
eyes open, eyes close and eyes vertical movements,
but the conscious is not affected.
BEHAVI
ORAL
STATE
DEFINITION
LESION
COMMENTS
Lockedin
syndrom
e
Patient alert and
aware, quadriplegic
with lower cranial
nerve palsy
Bilateral ventral
pontine
Persiste
nt
vegetati
ve state
Absent cognitive
function but retained
“vegetative”
components
Extensive cortical
Synonyms include apallic
gray or subcortical syndrome, coma vigil, cerebral
white matter with
cortical death
relative preservation
of brainstem
Abulia
Severe apathy: patient Bilateral frontal
neither speaks nor
medial
moves spontaneously
Catatoni Mute, with marked
a
decrease in motor
activity
Usually psychiatric
Similar state may be seen with
severe polyneuropathies,
myasthenia gravis,
neuromuscular blocking agents
Severe cases resemble
akinetic mutism, but patient is
alert and aware
May be mimicked by frontal
lobe dysfunction or drugs
•
•
Consciousness is maintained
by the normal functioning of
•
•
•
Coma results from lesions that affect
•
•
•
brainstem reticular activating system above the mid
pons
and its bilateral projections to the thalamus and
cerebral hemispheres.
either the reticular activating system
or both hemispheres.
The content of consciousness resides in the
cerebral hemispheres;
1· Supratentorial mass lesions
 2· Infratentorial mass lesions
 3· Metabolic

Severe traumatic brain injury,
 Poison taking,
 Medication,
 Happened in active state,
 The suddenly happen of coma after a meal

Common CO poisoning,
 CO2 poisoning,
 Chloride poisoning
 Mostly caused by poor ventilation of living or
working places of patients.


Coma after :

Fever

Severe headache

Precordial angina and profuse perspiration
•
•
•
•
•
•
•
•
•
Coma accompanied with:
Hyperspasmia
Vomiting
Hemiplegic paralysis
Incontinence of urine and feces
Right upper abdominal pain,
Eyelid edema
Asthma and cyanosis
Extremely thin
Injury happened in or longer than a week
before coma,
 Headaches, blurred vision and paroxysmal
dementia,
 Paroxysmal limbs convulsions, abnormal
sensation or numbness

Hypertension
 Liver disease
 Diabetes mellitus,
 Kidney disease,

Heart disease,
 Lungs
 Original infection
 Original endocrine disease history
 Tumor or cancer,

Endemic areas living history
 Toxic substances contacting history
 Radioactive materials exposure history
 Clues to the diagnosis of local and occupational
diseases


Family history

Congenital or genetic disease.
Basic vital signs
 General physical checkup
 The neurologic examination

Breathing,
 Body temperature,
 Heart rate
 Blood pressure.


Respiratory rate
Normal : 14-20 times/min,
 Bradypnea: <9 times/min

intracranial hypertension,
 respiratory failure,
 Slow and sighing like breath is mostly caused by
morphine poisoning;


Tachypnea: >30 times/min,

acute infections
•
•
•
Bilateral hemispheric or diencephalic damage: CheyneStokes respirations (CSR) are a patter of periodic
breathing in which phases of hyperpnea regularly
alternate with apnea.
Of all the respiratory patterns listed, this has the least
specificity.

Central neurogenic hyperventilation is a
sustained, rapid, and fairly deep hyperpnea that
often occurs in patients with dysfunction
involving the rostral brainstem tegmentum.
•
•
Apneustic breathing
prolonged inspiratory cramp
•
•
(a pause at full inspiration).
uncommon but localizes accurately to a lesion
in the mid- or caudal-pontine level.
•
•
•
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Ataxic breathing
(Biot’s respirations)
completely irregular and chaotic breathing pattern
deep and shallow breaths occur randomly.
The lesion involves the respiratory centers in the
reticular formation of the medulla that control the
normal to-and-fro pattern of breathing.

Shallow and regular breathing


Snoring breathing accompanied by one side of facioplegia


intra tracheal foreign body and severe laryngitis;
Inspiratory phase < expiratory phase


cerebral hemorrhage;
Inspiratory phase > expiratory phase (stridulous breathing)


low blood sugar;
chronic obstructive pulmonary disease;
Fast, deep and regular breathing

diabetic ketone poisoning, uremia, sepsis, and poisoning by methanol,
paraldehyde, vinylethyl alcohol and salicylates, often leading to respiratory
alkalosis.






Ammonia smell breath Fruity breath
Bitter almond smell breath
The garlic smell breath
Liver odor
Alcoholic smell plus
vomiting
-
uremia,
Diabetes
hydrocyanic acid
poisoning
organophosphate
poisoning
hepatic coma
excessive drinking





Infection
Absorption of necrosis,
Intracranial infection,
Brain hemorrhage.
Fever accompanied with neck soft


cerebral malaria;
Fever accompanied with neck rigidity
meningitis,
 encephalitis
 subarachnoid hemorrhage.


Hypothermia


Negative urine sugar accompanied with watery
stool


shock, hypoglycemia, poisoning and endocrine
dysfunction.
cholera,
Positive urine sugar

diabetic coma.

Accelerated heart rate


Fine and speed pulse


meningitis,
Slow and loud pulse


belladonna poisoning,
cerebral hemorrhage and alcoholism,
Slow and weak pulse

morphine poisoning..
Low blood pressure is likely seen in myocardial
infarction, pulmonary infarction, aneurysm
rupture, post-traumatic entorrhagia and the late
phase of severe intracranial hypertension,
 High blood pressure is likely seen in
hypertensive cerebral hemorrhage.



Dry and burning heat skin -thermoplegia;
Moist skin -hypoglycemia, morphine poisoning, myocardial
infarction and heatstroke;


Pallor -hypoglycemia and uremia;
Flushing -cerebral hemorrhage, alcoholism and belladonna
poisoning;



Jaundice -hepatic coma;
Bleeding spots -epidemic cerebrospinal meningitis;
Roseola -typhoid fever.

Cherry red lips


Cyanosis


carbon monoxide poisoning,
hypoxic diseases such as heart insufficiency and
pulmonary insufficiency,
Herpes

lobar pneumonia, meningococcal meningitis and
viral infection which is accompanied with vivax
malaria.
Panda eye signs such as bilateral periorbital blue，
nose bleeding or bloodstain, occipital or
postmastoid ecchymosis,
basal skull fracture.

Hemorrhagic shock


pneumohemothorax and abdominal internal
haemorrhage,
Fat embolism

long bone fracture.

Mental Status Examination
language function
 If no respond to verbal questioning, use painful
stimulation (deep nailbed pressure, sternal rub, or a
cotton swab inserted into the nasopharynx, etc)

voicelistening
eyes open
can locate the sting site
answer reply,
3 not
to
the 4 and raise hand to the 5
pain site
point
eyes
open
limbs can retract when
answer the
after
2
question not
3 sting
4
prickling
asked
can not
both upper limbs are
only make
open eyes 1
voice, no
2 hyperflexionwhen sting
3
language
all
limbs
are
can not make
1 hyperextension when sting 2
voice
body relaxation and
action when sting
no
1
•
Pupillary size depend on the balance between
•
parasympathetic nervous system
•
•
(causing constriction via cranial nerve III)
the sympathetic nervous system
•
(causing dilation via the complicated sympathetic
innervation of the pupil)
·Small pupils:
 Bilateral small and fixed pupils


pressure transmitted to the pons ,


A hemorrhage within the pons, for example,
Only one pupil is small and associated with
ptosis

(Horner’s syndrome),
•
Bilateral large pupils:
–
–
–
–
–
–
adrenergic stimulation
the stress of illness
in association with delirious states
drug withdrawals
epinephrine, atropine, and stimulant drugs (cocaine
and PCP)
Central herniation through the tentorial notch
results in bilateral third nerve palsies.
•
Ipsilateral large pupils:
–
ipsilateral 3rd nerve palsy
–
–
if a mass lesion with herniation causes the ipsilateral
uncus to push the 3rd cranial nerve against the
tentorium,.
A 3rd nerve palsy that came on suddenly in
association with a headache would imply a posterior
communicating aneurysm
The oculocephalic (Doll's eyes) and
oculovestibular (calorid testing)
 Doll's eyes phenomenon


when neck flexion, two eyelids are pulled up, two
eyes open widely and two eyeballs turn to the upper
side
Papilledema is seen in intracranial spaceoccupying lesions;
 Retinal exudation is seen in uremia;
 Fundus hemorrhage is seen in subarachnoid
hemorrhage or cerebral hemorrhage, and so on.

Coma patient in light extent may have
hypoalgesia and other superficial sense drops,
and will show frown or defensive reflex such as
avoidance to the pain stimuli;
 For the coma patients in deep extent, all senses
disappear completely.


Movement inspection
muscle strength
 muscle tone
 involuntary movements

Nervus supraorbitalis compression can be used
to observe the corners of mouth and limbs
movement,
 Limbs dropping test can be used to confirm
paralysis.


Flapping tremor


Paroxysmal hyperspasmia


CO, organic phosphorus, cyanide or strychnine poisoning;
Epileptic seizure


CO2, atropine or organic chlorine poisoning;
Tonic convulsion


hepatic coma or pulmonary encephalopathy;
hematencephalon, craniocerebral injury;
Choreiform movements

rheumatic encephalopathy.

Positive pathological reflexes


coma may caused by primary or secondary brain
lesions,
Positive meningeal irritatation sign
intracranial infection,
 subarachnoid hemorrhage,
 intracranial hypertension.

•
Decortical posturing (flexed arms and extended
legs)
•
•
a lesion at the level of the diencephalon or above.
Decerebrate posturing (extension of arms and
legs due to overactivation of the lateral
vestibulospinal tract)
•
rostral brain stem lesions.
The key organ that affecting the consciousness
is brain,
 The important organs that affecting the brain
function are heart, lungs, liver, kidneys,
pancreas, adrenal and blood system,

Cardiogenic
Coma and cardiac
arrest occur
simultaneously
Arterial pulse
disappears, heart
sounds disappear
Lips cyanosis,
respiratory arrest
Mydriasis and no light
reflex
Pulmonary
Chronic lung disease
history with acute infection
Chest tightness, cyanosis,
cough, tachypnea, frothy
sputum and other
symptoms
Concentration disperses,
indifferent, bluntness,
distracted and other
psychological symptoms,
and then transferred into
drowsiness, coma
Blood gas analysis shows
hypoxemia and
hypercapnia
Hepatic
Chronic liver disease history,
symptoms and signs, such as
liver palms, ascites, spider
angioma, etc.
Paroxysmal or persistent
psychiatric symptoms
(especially flapping tremor),
then gradually transferred into
coma
Hepatic odor with the
performance of multiple organ
failure when coma happened
Serious damage of liver
function, the ratio of albumin
and globulin upside down,
blood ammonia increases
EEG shows bilateral
symmetrical high amplitude θ
or δ waves
Nephrogenic
Pancreatic
Blood system
Late chronic kidney
Pancreatitis history, Anemia and
disease history with
symptoms and signs exsanguine blood
multiple organ failure Delirium and insanity disease history
Former psychiatric
happened 3-5d after Factors that can lead
symptoms such as
incidence of disease, to lack of cerebral
apathy, lack of
then transferred into blood flow and
concentration, delirium, coma gradually
nutrient substances
etc.
Performance of
such as severe
Miosis, light reflex and severe pancreatitis, anemia
oculovestibular reflex such as elevated
Advanced leukemia,
exist
serum amylase,
systemic failure
Uremic symptoms,
decreased serum
Disseminated
such as positive urinary calcium
intravascular
protein, increased blood concentration, etc
coagulation
urea nitrogen and
secondary other
creatinine,etc.
diseases

Low hemoglobin concentration of blood (HCB)



Increased leukocyte




anemia,
hemorrhagic shock;
severe infection,
cerebral hemorrhage,
post-traumatic stress;
Decrease leukocyte



viral encephalitis,
viral meningitis,
typhoid.

Positive urine glucose with positive ketones


diabetic ketoacidosis coma;
Positive urine glucose with negative ketones
diabetic lactic acidosis coma,
 diabetic hyperosmotic nonketonic coma,
 cerebral hemorrhage


Positive urinary protein
uremia,
 eclampsia accompanied with renal damage,
 hypertensive encephalopathy,
 cerebral hemorrhage


Positive urinary bilirubin and urobilin
hepatic coma,
 acute infection accompanied with liver damage.


Increased blood sugar
stress reaction
 diabetic coma ,ketone bodies should be further test
in order to confirm the cause of the diabetic coma;


Low blood sugar is common in severe liver
damage, insulin shock or islet cell tumor, and
so on.

Elevated blood ammonia


Hepatic coma (hepatic encephalopathy)
elevated blood ammonia accompanied with
normal liver function,

Hashimoto encephalopa should be rule

Bloody cerebrospinal fluid


Increased neutrophil


viral infection,
High content of sugar


intracranial bacterial purulent infection,
Increased lymphocytes


all types of intracranial hemorrhage,
diabetic,
lower content of sugar

intracranial infection and low blood sugar.

ECG
myocardial infarction,
 arrhythmia and so on,


EEG
Most EEG pattern of coma patients is continuous δ
wave;
 Epilepsy


CT or MRI

“A-B-Cs”

rule out primary cardiopulmonary cause
Immediately rule out hypoglycemia, or give
50% dextrose IV
 Urgent brain CT


(rule out blood or edema) if head trauma or
focal neuro deficit
Correct any hypothermia
 Check metabolic panel, drug screens





Urgent LP to rule out bacterial meningitis
If focal signs or papilledema, get brain CT first to
verify abscess or other mass lesion
Empirical IV ceftriaxone & vancomycin (&
ampicillin in older or debilitated adults)
If viral encephalitis suspected, get brain MRI, EEG,
CSF PCR for Herpes simplex


The treatment of coma depends on the cause,
General treatment rules (if the cause is unknown):"coma
cocktail"



thiamin (a vitamin that can help in alcoholic or nutritionally
starved patients),
glucose (a sugar that can help diabetics who have developed
a coma due to low sugar level),
naloxene (a substance that reverses the action of many
narcotics and is used to treat overdoses).
Correcting for Electrolyte Imbalance or Toxic
Substances
 Decreasing Intracranial Pressure

hyperventilation,
 Diuretics
 surgery
