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Coma

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mrbalwa419
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19 views

Coma

Uploaded by

mrbalwa419
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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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

 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

Is an absence of responsiveness and


awareness state due to overwhelming
dysfunction of the cerebral
hemispheres with sufficient sparing of
the diencephalon and brainstem to
preserve autonomic and motor reflexes
and sleep-wake cycle.
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.
Coma Etiology

 Primary CNS Structural lesions


1. Supratentorial (bilateral cerebral hemispheres affected)
2. Infratentorial (brainstem affected)
 Diffuse CNS dysfunction due to
Metabolic-Toxic causes.
Metabolic cause of Coma

 Respiratory  Hepatic
 Hypoxia encephalopathy
 Severe renal failure
 Hypercarbia
 Infectious
 Electrolyte  Meningitis
 Hypoglycemia  Malaria
 Hyponatremia  Encephalitis
 Hypercalcemia  Toxins, drugs
Primary CNS structural cause of Coma

Supratentorial Infratentorial
Hematoma Vascular accidents
Neoplasm Neoplasma
Abscess Trauma
Contusion Cerebellar hemorrhage
Vascular Accidents Demyelinating disease
Diffuse Axonal Central pontine
Damage 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/shock
Alcohol/Acidosis
Epilepsy/Endocrine
Insulin(hypoglycemia/hyperglycemia)
Oxygen(Hypoxia)/ opioids
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……
 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……

 Ifhead 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
 The head
1. Evidence of injury
2. 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
Glasgow Coma Scale

 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.
N.B: GCS is not useful for diagnosis but is used to follow
patient’s course and determine if the patient is improving or
deteriorating
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
COMA-Initial assessment cont……

Temperature
Hypothermia
 Hypopituitarism, Hypothyroidism
 Chlorpromazine
 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
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
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
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
Management of the Acutely
Comatose Patient
 Airway, Breathing, Intubate if GCS <8 or possible respiratory arrest.
 Coma cocktail if unknown origin: Glucose, Naloxone, Oxygen and
Thiamine .
 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.
Questions

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