COMA

DIAH MUSTIKA HW,SpS,KIC

INTENSIVE CARE UNIT of EMERGENCY DEPARTMENT
NAVAL HOSPITAL dr RAMELAN, SURABAYA

DEFINITIONS
Coma
State of unresponsiveness to external or internal stimuli
in which a patient lies w/ eyes closed unaware of the
environment
Consciousness
State of awareness of both the self and the environment
ARAS : rostral pons,
midbrain, thalamus,
hypothalamus
Wakefullness or alertness
Arousal
Cerebral cortex and
connection to subcortical
white matter
Attention, memory,motivation
and executive function
Content
Alert : fully consciousAAlert: Fully conscious

Lethargic: appear somnolent, but may be able to maintain
arousal spontaneously or with repeated light stimulation

Obtunded: requires touch or voice to maintain arousal

Stuporous: unresponsiveness from which the individual can
be aroused only by vigorous and repeated stimulus

Comatose: state of unarousable unresponsiveness in which
individual lies with eyes closed, lacking awareness of self
and environment
Levels of Arousal:
Motor
Response Example Score
Commands Follows simple commands 6
Localizes
Pain
Pulls examiner's hand away
when pinched 5
Withdraws
from Pain
Pulls a part of body away when
pinched 4
Abnormal
Flexion
Flexes body inappropriately to
pain 3
Abnormal
Extension
Body becomes rigid in an
extended position when
examiner pinches him 2
No Response Has no motor response to pinch 1
Eye-Opening .
Spontaneous Opens eyes on own 4
To Voice
Opens eyes when asked to
in a loud voice 3
To Pain Opens eyes when pinched 2
No Response Does not open eyes 1
Verbal Response
(Talking) .
Orientated
Carries on a conversation
correctly and tells examiner
where he is, who he is, and
the month and year 5
Confused
Conversation
Seems confused or
disoriented 4
Inappropriate Words
Talks so examiner can
understand him but makes
no sense 3
Sounds
Makes sounds that
examiner cannot understand 2
No Response Makes no noise 1
EMERGENT MANAGEMENT

Stabilization:
Airway
Assess for patency
Assess for ability to protect

Breathing
Assess ventilation
Assess breathing pattern

Circulation
Assess measures of cardiac output
Hyper or hypothermia should reversed
appropriately to normothermia
Evaluation:
History
Physical Exam
Laboratory and Imaging Studies
EvaluationHistory:
Rapid initial history:
Recent history prior to mental status changes
Past medical history (seizures)
Family history (specifically seizures/neurologic disorders)
Trauma ?
Febrile ? / Other signs or symptoms of infection
Diet
Exposure to drugs/toxins

Follow-up with more complete history:
EvaluationPhysical Exam:
Systemic
Vital Signs
Signs of trauma
Signs of infection
Signs of bleeding
Signs of other systemic illnesses

EvaluationPhysical Exam:
Rapid Neurologic Exam:
Pupils
Respiratory pattern
Stimuli needed to elicit response
Character of the response

Neurologic ExamPupils:

Respiratory patterns:
Cheyne-Stokes
Central
Hyperventilation
Apneustic
Cluster
breathing/Gasping
Agonal breathing
Hemispheric
Midbrain
Mid/Lower Pons
Low Pons/Upper
Medulla
Medulla
Location
Pattern
Posturing:


Decorticate
lesion above
midbrain
Decerebrate
lesion below
midbrain
Common etiologies of coma
Structural Lesions
Supratentorial
Generalized/bilateral
Infectious/positinfectious
Encephalitis
Acute disseminated encephalomyelitis
Vascular
Anoxic ischmenic encephalopathy
Multiple cortical infarctions
Bilateral thalamic infarctions
Traumatic
Diffuse axonal injury
Penetrating brain injury
Multiple contusions
Neoplastic
Glimatosis
Leukoencephalopathy
Multiple brain metastases
Lymphoma

Focal (with mass effect)
Intraparenchymal hematoma
Large stroke with edema
Abscess
Tumor
Infratentorial
Brain stem
Pontine hemorrhage
Basilar artery thrombis
Central pontine myelinolysis
Cerebellum
Infraction with edema
Hematoma
Abscess
Tumor
Metabolic derangements
Hypoglycemia
Hyperglycemia (nonketotic hyperosmolar)
Hyponatremia
Hypercalcemia
Panhypopituitarism
Hyperbilirubinemia
Acute uremia
Diffuse Physiologic Brain Dysfunction
Status epilepticus
Poisoning
Drug overdose
Gas inhalation
Hypotthermia
Basiliar migraine
Malignant neuroleptic syndrome
Hypoxia

Psychogenic Unresponsiveness
Catatonia
Conversion disorder
Malingering
Adapted from Ziai WC. Coma and altered consciousness. In Bhardwaj A, Mirski
MS, Ulatowski JA (eds), Current Clinical Neurology : Handbook of Neurocritical
Care. Totowa, NJ : Humana Press, 2004, pp 1 18

Thanks for your attention