Professional Documents
Culture Documents
Presented by
Dr. Mahmudul Hasan
What is a "coma"?
Coma is a state of unconsciousness whereby
a patient cannot react with the surrounding
environment. The patient cannot be wakened
with outside physical or auditory stimulation.
Pathophysiology
Pathophysiology
Pathophysiology
Pathophysiology
So the principal ways to develop coma :
Damage to RAS and its projections
Damage to both cerebral hemisphere
Suppression of reticulo-cerebral
function by drugs ,toxins
hypoglycemia , hepatic failure or
azotemia etc..
Classification
Plum and Posner classify coma either :
1) supratentoral (above Tentorium cerebelli,
2) infratentoral (below Tentorium cerebelli)
3) metabolic or
4) diffuse.
CAUSES OF COMA
Metabolic disturbance
Drug overdose
Hyponatraemia
Uraemia
Hepatic failure
Respiratory failure
Hypothermia
Hypothyroidism
Diabetes mellitus:
Hypoglycaemia
Ketoacidosis
Hyperosmolar coma
CAUSES
Trauma
Cerebral contusion
Extradural haematoma
Subdural haematoma
CAUSES
Cerebrovascular disease
Subarachnoid haemorrhage
Intracerebral haemorrhage
Brain-stem infarction/haemorrhage
Cerebral venous sinus thrombosis
CAUSES
Infections
Meningitis
Encephalitis
Cerebral abscess
General sepsis
CAUSES
Others
Epilepsy
Brain tumour
Thiamin deficiency
Approach
History
(1) The circumstances and rapidity with which
neurological symptoms developed;
(2)The antecedent symptoms (confusion,
weakness, headache, fever, seizures,
dizziness, double vision, or vomiting);
(3)The use of medications, illicit drugs, or
alcohol; and
(4)Chronic liver, kidney, lung, heart, or other
medical disease.
Approach
Approach
Approach
Neurologic Examination
First, the patient should be observed
without intervention by the examiner.
Tossing about in the bed, reaching up
toward the face, crossing legs, yawning,
swallowing, coughing, or moaning denote a
state close to normal awakeness.
Lack of restless movements on one side or
an outturned leg suggests a hemiplegia.
Intermittent twitching movements of a foot,
finger, or facial muscle may be the only
sign of seizures.
Approach
Level of Arousal
A sequence of increasingly intense stimuli is
used to determine the threshold for arousal
and the optimal motor response of each
side of the body. The results of testing may
vary from minute to minute and serial
examinations are most useful.
Tickling the nostrils with a cotton wisp is a
moderate stimulus to arousalall but
deeply stuporous and comatose patients
will move the head away and rouse to some
degree.
Approach
Approach
Brainstem Reflexes
1.
2.
3.
4.
Approach
Pupillary Signs:
Approach
Approach
Approach
Ocular Movements
The eyes are first observed by elevating the
lids and noting the resting position and
spontaneous movements of the globes. Lid
tone, tested by lifting the eyelids and
noting their resistance to opening and the
speed of closure, is reduced progressively
as coma deepens. Horizontal divergence of
the eyes at rest is normal in drowsiness. As
coma deepens, the ocular axes may
become parallel again.
Approach
Respiratory Patterns
Treatment
Coma is a medical emergency, and attention
must first be directed to:
maintaining the patient's respiration and
circulation, using intubation and ventilation,
administration of intravenous fluids blood
and other supportive care as needed.
Once a patient is stable and no longer in
immediate danger, the medical staff may
concentrate on maintaining the health of
patients physical state.
Treatment
Treatment
Follow up
BP 2 hourly
Temperature 2 hourly
Strict intake output chart
4 hourly blood gases
Continuous monitoring of oxygen saturation
with pulse oxymetry
Blood glucose 4 hourly
Ca and ph 12 hourly
Urea and electrolytes twice daily
Prognosis