Coma

COMA
DR. SHAFAQ SHAIKH
FCPS II TRAINEE

What is coma?

 A coma ( from the Greek Koma, meaning
deep sleep) is a profound state of
unconsciousness, in which a person is
unresponsive and unarousable.
 Reflex movements and posturing maybe
present

Biology of consciousness

 Two components of conscious behavior
 content- the sum of cognitive and affective
function
 arousal- appearance of wakefulness
 Content depends on arousal but normal
arousal does not guarantee normal content

Epidemiology of Coma

 Plum and Posner
 500 consecutive cases of coma
 101 supratentorial (44/101 ICH)
 65 subtentorial lesions (40/65 brainstem infarcts)
 326 diffuse or metabolic brain dysfunction
 149 drug intoxication

CAUSES

 According to etiology
 Traumatic
 Metabolic
 Vascular
 Infectious
 Toxic
 Structural
 Psychogenic

 Focal versus nonfocal.
 Focal: intracerebral hemorrhage, ischemic
stroke, demyelinating diseases.
 Nonfocal: vascular, toxic, metabolic
conditions, nutritional
deficiencies, seizures, psychiatric conditions.
 Either: trauma, infections, tumors

DIAGNOSIS

 Medical History
 Physical Exam & Neurological Evaluation
 Eye Examination
 Laboratory Tests
 Imaging Studies
 EEG

Clues from History

 Onset of symptoms
 sudden onset
 fluctuations
 Associated neurologic symptoms
 Medications

Physical examination

 General examination. A thorough general
examination, including vital signs, helps to
establish and rule out potential causes of
coma. Look for evidence of head trauma or
metabolic encephalopathy.

Breathing

 . Cheyne-Stokes respiration: cerebral
hemispheric or diencephalic injury or an
encephalopathy (hypoxic or metabolic).
 Central hyperventilation: brainstem injury.
 Ataxic or Biot’s respiration, which can
progress to apnea: injury to the reticular
formation in the medulla and pons.

Eye examination

Pupils (size, shape, position, PERLA)
- Unilateral horner syndrome= hypothalamic
lesion
- Ipsilaterl pupil dilation= 3rd nerve palsy due to
uncal herniation
- Smaller than normal but reactive= metabolic
encephalopathy
- Fixed, dilated= overdose of atropine
- Pinpoint, responsive= opiates

eye examination
 Corneal reflex
 Ciliospinal reflex
 Eye movements
 Oculocephalic/ calorics
 fundoscopy

Cranial Nerve Exam

 Cranial Nerve Exam
 Pupillary light response (CN 2-3)
 Occulocephalic/calorics (CN 3,4,6,8)
 Corneal reflex (CN 5,7)
 Gag refelx (CN 9,10)

Motor Exam

 Assess tone, presence of asterixis
 Response to painful stimuli
 none
 abnormal flexor
 abnormal extensor
 normal localization/withdrawal
 Reflexes

The Glasgow Coma Scale

EYE OPENING VERBAL RESPONSE MOTOR RESPONSE

Spontaneous 4 Oriented 5 Obeys command 6

To speech 3 Confused 4 Localizes pain 5

To pain 2 Inappropriate words 3 Withdraws 4

None 1 Incomprehensible words 2 Abnormal flexor posturing
3
None 1 Abnormal extensor
posturing 2

LABS

 Blood cp
 Blood glucose
 Serum eletrolytes
 Serum calcium
 ABGs
 Liver and renal function tests
 Toxicologic studies

Other investigations

 Imaging studies: CAT scan, MRI
 EEG, BCI
 LP

TREATMENT

 Recovery position

TREATMENT

 Appropriate treatment must be commenced
concomitantly with routine measures
 Treat according to the cause
 The "Coma Cocktail"
It's a mixture of thiamine 50mg , dextrose 50 %
(25g) , and naloxene 0.4-1.2 mg given
intravenously.

Other treatments

 Antibiotics
 Anticonvulsants
 Warm the pt if hypothermic
 Correct any electrolyte or metabolic
imbalance
 Reduce raised ICP with diuretics or surgery
 Ventilation/ cardiovascular support

Long term treatment

 preventing infections such as pneumonia
 maintaining the patient's physical state
(preventing bed sores, for example)
 providing adequate nutrition.

PROGNOSIS

 The prognosis in comatose patients is
typically poor except for those that are drug-
related or result from traumas. In general, the
longer the coma lasts, the poorer the
prognosis. Coma rarely lasts longer than 4
weeks, after which, transition into a
vegetative state or recovery occurs

Coma

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