Comatose

Dr Tanveer Hj Iqbal

Lecture Outcome

Define the different states of reduced alertness: comatose, stupor and

drowsiness

State the difference between coma and related condition: vegetative state,
minimally conscious , locked-in coma, brain death

Identify the causes of comatose and understand the mechanism of each

cause.

List the appropriate investigation

Describe differential diagnosis of coma

Outline the general management of comatose patient

INTRODUCTION

The brain requires a constant supply of oxygenated blood and glucose to

function.

Interruption of this supply will cause loss of consciousness within a few

seconds and permanent brain damage in minutes.

MEANING OF CONSCIOUSNESS
It is a state of that has three important aspects1)

wakefulness;

2)

Awareness of self,

3)

Awareness of environment and time.

LEVELS OF UNCONSCIOUSNESS

Stupor
In stupor, patient responds to external stimuli and shows the symptoms of
annoyance when stimulated by pinprick or loud noise such as clapping of
hands.

Drowsiness
a state when patient feels drowsy or sleepy or we can say it is a state
between sleeping and awakening.

Coma
unarousable unresponsiveness

ETIOLOGY

Structural lesions

Structural lesions

Supratentorial lesions (causing brain stem dysfunction)

E.g.
EDH/SDH
Brain abscess
Cerebral infarction

Structural lesions

CEREBRAL HEMORRHAGE

BRAIN TUMOR

Structural lesions
2. Subtentorial lesions
compressing/destroying
the reticular formation
E.g. Cerebellar abscess

Infarction
cerebellar hemorrhage
/tumor

Metabolic disorder &

diffuse lesions
Diabetic

coma :-

cellular
Hepatic

coma :-

accumulation of waste product in systemic circulation.

Fluid

and electrolyte imbalance

Na+ and osmolar imbalance in CNS

Nutritional
Anoxia

starvation, ketone bodies

deficiency

or ischemia :- Po2<25mmhg

Disease of neuron e.g.. Lesions of motor neuron

Other cause

Concussion and postictal states

Drug overdose e.g. Sedatives, analgesic, alcohol

Decrease HR, BP, RR, Tempt.

Anesthetic agent

RTI

UTI

Psychogenic causes

hysteria or catatonia

GCS scoring

Glasgow Coma Scale (GCS)

Assess neurological function by using Glasgow Coma Scale (GCS)

Score range - 3 to 15
Parameter

Eye opening
Best verbal response
Best motor response

GCS
1.

PARAMETER

FINDINGS

SCORE

Eye opening

spontaneous

to speech
To pain
do not open

2.

Best verbal response

3
2
1

Oriented

confused

inappropriate speech

incomprehensible sound

no verbalization

GCS
Best motor response

obeys command

localizes pain

withdraws from pain

Abnormal flexion
(decorticate posture)

abnormal extension
(decerebrate posture)

No motor response

PHYSICAL ASSESSMENT

Voluntary movement- strength and asymmetry in the upper extremities

Deep tendon reflexes- biceps, triceps & patella.

Posture:

Decerebrate

Decorticate

contd

You are in emergency department when an

unconscious patient land in emergency with B.P
90/50 pulse 92/min and attendants tell u that the
patient suddenly fell unconscious, how will you
approach ?

APPROACH

DRS ABCD

Immediate management

Examination

History

Investigations

Immediate management

Maintain i.v line, oxygen inhalation

Blood sample for RBS

Control seizures

Consider i.v glucose, thiamine, naloxone, flumazenil

Examination

Examination

Vitals
Skin petechial
rash
Injection marks

Neurological
assessment
Neck rigidity
Fundoscopy
Brainstem reflexes

Detailed medical
examination

Vital signs
1.Pulse
Tachycardia
Hypovolemia/haemorrhage
hyperthermia
Intoxication
Bradycardia
Raised intracranial pressure
Heart blocks

Vital signs
2.Temperature
Increased
Sepsis
Meningitis ,encephalitis
Malaria ,Pontine haemorrhage
Decreased
Hypoglycemia
Hypothermia (less than 31 C)
Myxedema
Alcohol, barbiturate ,sedative or phenothiazine intoxication.

Vital signs
3.Blood pressure
Increased
Hypertensive encephalopathy
Cerebral haemorrhage
Raised intracranial pressure
Decreased
Hypovolemia /hgr
Myocardial infarction
Intoxication/poisoning
Profound hypothyroidism, Addisonian crisis

Vital signs
4.Respiratory rate
Increased(tachypnae)
Pneumonia
Acidosis (DKA, renal failure)
Pulmonary embolism
Respiratory failure
Decreased
Intoxication/poisoning

General Examination
Skin petechial rash

Meningococcal meningitis

Endocarditis

Sepsis,thrombotic thrombocytopenic purpura

Rickettsial infection
RMS (rocky mountain spotted fever)

General Examination

Multiple injection marks

Drug addiction

Acute endocarditis

Hepatitis B /C with encephalopathy

HIV

General Examination

Neurological assessment;

General posture

Level of conciousness

General Examination
Posture

Lack of movements on one side

Intermittent twitching

Multifocal myoclonus

DECORTICATION

DECEREBRATION

GCS scoring

Level of conciousness

Glasgow coma scale (GCS)

Best motor response

Best verbal response
Eye opening
GCS score 3 severe injury
less than or equal to 8 moderate injury
9 to 12 minor injury

AVPU scale

An abbreviated coma scale is used in the assessment

of critically ill patient (primary servey)

AVPU
A alert
V respond to voice stimulus
P respond to pain
U - unresponsive

Brainstem reflexes

Pupillary responses to light

Spontaneous and elicited eye movements

Corneal responses

Respiratory movements