Clinical Approach

to coma
-BY 6TH YEAR MEDICAL STUDENT
Index:

1. Definition
2. Levels of Arousal
3. Causes
4. Clinical Approach
5. Investigations
6. General Management
7. Complications (and their management)
1. Definition of Coma

 Coma is unconscious sleep like state from which patient can’t be

aroused despite vigorous noxious stimuli
2. Levels of Arousal

Confused Drowsy Stupor Coma

Sleepy but can be Deep sleep but can be Unconscious not
Conscious but talks
aroused easily by aroused by painful responding to
irrelevantly
external stimuli stimuli external stimuli

1 2 3 4
3. Causes of Coma
A. Diffuse brain Dysfunction

 Traumatic : Cerebral concussion, contusion or laceration

 Infectious : Meningitis , Encephalitis , Malaria , Typhoid or Rabies
 Endocrinal :
Thyroid (myxedema or thyrotoxicosis)
Parathyroid (hypo or hyper Para-thyroidism )
Addison Disease
Hypopituitarism
 Metabolic :
hypo or hyper Glycemia
hypo or hyper Thermia
Hypoxia
Hepatic Encephalopathy
A. Diffuse brain Dysfunction: ”continue”

 Electrolytes & Acid-Base Disorders: hypo or hyper (K,Na,Mg,PO4)

Acidosis , Alkalosis.

 Ischemic: Cardiac Arrest, Arrythmia, Shock, Hypo-tension, MI.

 Toxicity: Opiates, Barbiturates, Alcohols, Atropine, Salicylates, Sedatives.

 Post-Ictal: Post-Epileptic
B. Localized RAS lesions

 Vascular:
-Hemorrhage (cerebral , subarachnoid Hge , epidural & subdural Hematoma)
-Cerebral thrombosis or embolism e.g. Basilar Artery Occlusion

 Inflammatory :
-Basal Meningitis& encephalitis -Abscess -Brainstem Demyelination

 Neoplastic :
-1ry: as Meningioma , Glioma , Acoustic Neuroma....
-2ry Metastatic tumors

 Traumatic : -Basal head trauma , fratures and herniation

4.Clinical Approach

Initial Stabilization
 The initial stabilization of comatose patients is the same as that for that of all
emergency department patients and consists of securing the patients airway (with
attention to the cervical spine), breathing, and circulation.

 Concurrently with airway management, the cervical spine must be stabilized

whenever there is a possibility that the patient’s alteration in mental status has a
traumatic cause. Cervical spine injuries are commonly associated with alterations
mental status of traumatic cause, occurring in 5% or more of such patients.

 GCS of 8 or less in a trauma patients often viewed as an indication for intubation.

Glasgow Coma Scale
History
 Comatose patients by definition cannot give details of their illness, so They can relay
information obtained from family members
 Describe the patient’s initial level of consciousness and how the patient was found
(for Trauma)
 Drugs ? For (addiction)
 Establish the rate of progression of Symptoms as onset ?

( Coma because of subarachnoid hemorrhage, cerebellar infarction, is usually of abrupt

onset, whereas coma from infection may evolve over hours to days. poisoning may occur
over minutes if caused by a large dose of drug (e.g. an opioid)

 Importantly, when obtaining historical information, providers must avoid the errors of
premature closure and diagnostic anchoring. For example SDH and hypoglycemia are life
threatening causes of coma that may coexist with ethanol intoxication.3
Physical Examination
A complete physical examination will provide clues to the diagnosis of coma and help Stream line the
patient’s diagnostic evaluation. Crucial physical examination findings, and the important causes of
coma associated with them

Vital Signs
Pulse?
 Bradycardia
context of sympatholytic drugs, such as clonidine; in the setting of sedative hypnotic toxicity, particularly with
barbiturates and gamma-hydroxybutyrates and with increases in intracranial pressure .
 Tachycardia adrenergic hyperactivity from intracranial hemorrhage

Blood Pressure?
 Hypotension may occur in sepsis and many poisonings ,
 Hypertension for the diagnosis of hypertensive encephalopathy
.

 Respiratory Rate?
Tachypnea is common with metabolic acidosis of any cause.
Bradypnea may be seen in both opioid and sedative-hypnotic toxicity.
 Temperature?
Hyperthermia may be due to salicylate poisoning, and several primary CNS disorders, including(SAH)
Hypothermia due to sedative-hypnotic toxicity, hypothyroidism

Physical Examination (Head, eyes, ears, , skin )

 Head Examination
may show obvious signs of deformity such as crepitus in the setting of a skull fracture .
 Eyes
Miosis is commonly seen in opioid.
Mydriasis is common in poisoning with compounds with anticholinergic properties eg. TCA
Horizontal nystagmus is common in ethanol intoxication.
 Ears
Hemotympanum may be seen in approximately 50% of basilar skull fractures.
 Skin
Small linear areas of pinprick-size trauma over veins (track marks) suggest the ongoing abuse of intravenous
drugs.
Neurological examination

 Sign of lateralization ; denoting intra cranial causes of coma

 Signs of meningeal irritation

 Fundus examination : papilledema

6. General Management
Resuscitation, Stabilization, identification

 An ABCDEF approach for initial assessment is appropriate.

 A: Airway
 B: Breathing
 C: Circulation
 D: Disability, Decontamination
 E: Exposure, Enhanced Elimination
 F: Focused Therapy
Recognize and Treat

Yes Oxygen
Monitoring
IV Access
Signs of life? Resuscitation team

Resuscitation team
Start CPR 30:2 w’ Oxygen
No
DC
ALS
Further Management:
 Where there is a history of trauma, cervical spine immobilization must be
implemented.

 Indications for endotracheal intubation include GCS <8, loss of laryngeal

reflex, refractory seizures.

 Take a sample for blood gases analysis, asses blood glucose.

 initial targets should be PaCO2 4.5-5.5 kPa, and PaO2 >13 kPa until
information regarding the cause of the coma can be established.
 Coma Cocktail (IV) : DON’T

D: Dextrose 25 g O: Oxygen
N: Naloxone 0.4-1.2 mg T: Thiamine 100 mg

 IV fluids ± vasopressors till achieve mean ABP of 90mmHg.

 Phenytoin if seizures present.

 IV antibiotics and blood culture if sepsis suspected.

 Treat the identified cause (DKA, Uremia, Electrolytes, etc.…).

Investigations
 Labs:

 Arterial blood gases analysis.

 Serum glucose, Ca, Na, K, Mg, Po4, urea and creatinine.
 Liver function tests and INR for hepatic failure.
 Drug screen.
 Blood culture in sepsis.
 Pyruvate, serum thiamine for Wernicke encephalopathy.
 Lumbar puncture and CSF analysis for meningitis.
 Imaging:
 CT brain for ICH, mass lesions (Abscess, tumor, hematoma), herniation
syndrome, unenhanced CT first then CT with contrast.
 MRI for more detail and showing multiple lesions (Metastases).
 EEG is helpful to detect seizures.
 EMG to exclude neuromuscular cause.
6.Complications (and their management)

 A. Complications of bedridden patient

 B. Complications after the recovery

A. Complications of bedridden patient

 Musculoskeletal and skin

 Respiratory complications

 CVS complications

 GIT complications
Musculoskeletal and skin
Complication Management

Bedsores Frequent Mobilization and Pneumatic

mattress

Joint stiffness Physiotherapy

Muscle Atrophy
Contracture
Bone Demineralization
Respiratory complications

Complications Management

Chest infections Prevention of Aspiration

Good Nutrition
Ventilator sterile condition
Early Management

Ventilation Proper Adjustment to the Device

&
Intubation

Pulmonary Embolism Elastic Stocking

Proper Hydration
Prophylactic Anti-Coagulants
CVS Complications
Complication Management

DVT Formation Elastic Stocking

Proper Hydration
Prophylactic Anti-Coagulants

Central Venous Line Access Access Under US Guidance

GIT & Urinary complications
Complications Management

Incontinence Diapers
Constipation Daily Enema
Fecal Impaction Proper Hygiene
Proper Hydration & Nutrition

Poor Oral Hygiene Proper Oral Hygiene

Urinary Management Catheter

(foley-condom)
B. Complications after the recovery

It is mainly psychological in the form of:

 Confusion
 Anxiety
 Depression
 loss of self esteem
REFERENCES
 Schenarts PJ, Diaz J, Kaiser C, et al. Prospective comparison of admission
computed tomographic scan and plain films of the upper cervical spine in trauma
patients with altered mental status. J Trauma 2001;51(4):663–8

 Dunham CM, Barraco RD, Clark DE, et al, EAST Practice Management
Guidelines Work Group. Guidelines for emergency tracheal intubation
immediately after79
 Heninger M. Subdural hematoma occurrence: comparison between ethanol
andcocaine use at death. Am J Forensic Med Pathol 2013;34(3):237–41.
 Williams HE. Alcoholic hypoglycemia and ketoacidosis [review]. Med Clin Nort
Am 1984;68(1):33–8.
 May R, Hunt K, Clinical approach to comatose patients, Anesthesia and
intensive care medicine, https://doi.org/ 10.1016/j.mpaic.2019.10.015.
 The Resuscitation Council (UK), M www.resus.org.uk
Names:
 Bashar Samir Abdalqader 1084
 Shadad Thabet Alwawi 1083
 Abdalaziz Hussien Elrayyes 1082
THANK YOU!