Thursday, August 1

3, 2015

Dr. Raj Gopal. V

Definition of COMA
Coma is defined as a sleeplike state with total absence
of awareness of self and the environment, even after
vigorous external stimulation. Coma is the most severe
form of unresponsiveness, and by definition, comatose
patients lie with their eyes closed.
In general a
comatose person is:
Apparently asleep.
Closing the eyes.
Not talking.
Unresponsive to instructions.
Without any voluntary movements.
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

The various states of consciousness

For consciousness to be intact the cerebral hemispheres must be activated by the Reticular
Activating System in the brainstem.

Conscious
state

Alert and oriented

Drowsy

Sleepy but can be woken up

Stupor

Unconscious but responds to vigorous stimulation

Coma

Unconscious and unresponsive

(Never lasts more than 2-4 weeks)

PVS
(Persistent
Vegetative
State)

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

All cognitive functions lost.

Maybe awake but totally
unresponsive. Breathing, circulation
and internal organ functions intact.
May last for years.

Pathophysiology of coma
Primarily 2 mechanisms:
A diffuse insult to both cerebral hemispheres.
A focal lesion in the Reticular Activating
System (RAS) in the upper Pons, midbrain or
the Diencephalon.
The Big-3 causes: Stroke, Trauma, Drug
overdose (STD!).
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

COMA

RAS

(Diencephalon)

Thursday, August 1
3, 2015

COMA

(Pons,
Medulla)
Dr. Raj
Gopal.
V

Causes of COMA
Two broad categories: Structural or surgical
and Metabolic or Medical.
Structural/Surgical: Diffuse damage to both cerebral
hemispheres due to vascular damage or raised
intracranial pressure.
Medical/Metabolic: Diffuse insult to both cerebral
hemispheres by toxins, either from within or from
outside.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Causes of COMA
Remember AEIOU-TIPS
A: Alcohol.
E: Epilepsy or Exposure to heat and cold
I: Insulin (Diabetic emergencies)
O: Overdose or Oxygen deficiency
U: Uremia (kidney failure)
T: Trauma (Shock or head injury)
I: Infection or Iatrogenic.
P: Psychosis or poisoning.
S: Strokes.
There are 424 causes of COMA!
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Causes of Surgical or Structural COMA

Trauma: Subdural/Epidural/Penetrating head injuries,
brain contusions.
Intracranial Hemorrhage: Subarachnoid or
intracerebral.
Ischemic Stroke.
Diffuse microvascular abnormalities like purpura,
Cerebral Malaria, Rocky Mountain Spotted Fever.
Tumors, either primary brain tumors or metastasis.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Causes of Metabolic or Medical COMA

Drug overdose: Benzodiazepines, Barbiturates, Opioids,
Anti-depressants.
Infections: Bacterial meningitis, Encephalitis, Sepsis.
Endocrine disorders: Diabetic emergencies, Myxedema,
hyperthyroidism.
Metabolic causes: Hyponatremia, Hypernatremia,
Uraemia, Hypoxia, hepatic coma, Hypertensive
encephalopathy.
Toxic: Carbon Monoxide poisoning, Alcohol,
Acetaminophen Overdose.
Medication side effects.
Hypothermia or hyperthermia.
Deficiency states: Thiamine (In alcoholics) and Niacin.
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Differences
Differences between Structural or surgical and
Metabolic or Medical.
Structural/Surgical: Focal neurological signs, dilated
and unreactive pupils and increased intracranial
pressure.
Medical/Metabolic: Reactive pupils, no focal
neurological signs and normal intracranial pressures.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Diagnosis of COMA
History from third parties like family, friends and
emergency medical personnel. Ask relevant
questions.
Clinical Examination: Quick and precise.
Rapid and appropriate investigations: To find cause
and institute appropriate treatment.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Assessment of COMA
The level of coma is assessed by the Glasgow
Coma Scale. A quick assessment is the AVPU
scale, used by emergency medical personnel:
A:
V:
P:
U:

Alert.
Responds to verbal commands.
Responds to pain.
Unresponsive - - - - - Proceed to GCS.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Assessment of COMA
The level of coma is assessed by the Glasgow
Coma Scale. GCS assesses:
Best verbal response.
Best motor response.
Level of stimulus needed to make the patient
open the eyes.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

The Glasgow Coma Scale

EYE OPENING
Spontaneous
To speech
To pain
No response

MOTOR RESPONSE

4
3
2
1

Obeys
Localizes
Withdraws
Abnormal flexion
Extension Posturing
No response

VERBAL RESPONSE
Oriented
Confused conversation
Inappropriate words
Incomprehensible sounds
No response
Thursday, August 1
3, 2015

5
4
3
2
1

6
5
4
3
2
1

Total score: E + M + V
Range: 3 15.
Mild coma: 13 15
Moderate coma: 9 12
Severe coma: < 8
Dr. Raj Gopal. V

Examination of a Comatose patient

Baseline: HR, BP, Rectal temperature, Oxygen saturation
and capillary Glucose.
Response to external stimuli: None.
Signs of trauma.
Skin and mucus membranes survey: hyperpigmentation,
cherry red color, anaemia, jaundice, rashes, IV drug abuse
sites, myxoedema.
Any MedicAlert bracelets or cards?
Breath smell: Ketones, alcohol, Solvents.
Examine RS, CVS, PA.
Neurological examination including meningeal signs.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Neurological examination
The neurological examination focuses on 4
components.
Respiratory patterns.
Pupillary responses.
Eye movements.
Motor responses.
The most important examination in coma (to identify the
cause) is the examination of the pupillary response
and eye movements.
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Respiratory patterns
Pattern

Lesion

Description

Cheyne-Stokes

Forebrain to
pons

Hyperventilation and
hypoventilation with pauses.

Central Neurogenic Midbrain to

pons
Hyperventilation

Rapid, deep breathing

Apneustic
breathing

Pons

Prolonged inspiratory gasp followed

by a pause and then expiration

Cluster breathing

High
medullary
lesions

Periodic breathing with irregular

frequency
and amplitude, along with variable pauses

Ataxic breathing

Medulla

Irregular in rate and rhythm

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Pupillary responses
Most important part of examination.
Pupils that react to light and are equal in size: Metabolic or
medical coma.
Unreactive, unequal and dilated pupil: Neurosurgical
emergency.
Pinpoint pupils: Pontine lesions or opiate toxicity.
Bilateral dilated, unresponsive pupils: Anoxia, severe
midbrain damage or anticholinergic drugs.
No pupillary abnormality: Excludes lesions below pons and
above thalamus.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Eye movements
Roving, slow, conjugate, lateral to and fro movements: Metabolic
encephalopathies or bilateral lesions above brainstem.
Ocular bobbing: Rapid downward jerk and slow return to
midposition of both eyes: Bilateral pontine lesions.
Ocular dipping: Slow downward dipping followed by brisk return:
Diffuse cerebral damage.
Skew deviation in horizontal plane; Cerebellar or pontine lesion.
Dolls eye reflex: Normally when the head is turned in a lateral
plane the eyes move in the opposite direction. Absence of this
response indicates brainstem lesion.
Caloric testing: 40-60 mL of ice cold water in the ears will cause
the eyes to move towards the irrigated ear. Absence indicates
brainstem damage.
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Motor responses
Spontaneous movements always good sign.
One side paralyzed: Suspect lesion in brain on the side
not moving.
Decorticate posturing: Arms flexed and legs extended
indicates lesions above brainstem or a metabolic cause.
Decerebrate posturing; Arms extended and legs extended
indicates bilateral midbrain or pontine lesion. Worse
prognosis. Also seen in metabolic conditions sometimes.
Myoclonus: Non-rhythmic jerking in single or multiple
muscle groups suggests metabolic encephalopathies
(hepatic chiefly).

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Investigations
Full blood counts: Infections.
Biochemistry: Electrolytes, sugar, LFTs, KFTs.
Arterial blood gases: Oxygen, CO2, pH, HCO3.
Blood cultures.
Alcohol levels.
Drug screen (urine and blood)
Lumbar puncture: Infections.
CT Scans in case of trauma, bleeds, hemorrhage.
MRIs where possible.
Thyroid function tests (rarely)
Electroencephalogram (EEG) & ECG.
CXR.
Blood slides for Malaria!!
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Management
Immediate management in hospital:
Never forget ABC: Airway, Breathing, Circulation.
COMA COCKTAIL: 50 mL of 50% Dextrose + Thiamine
100 mg + Naloxone 0.4 mg (adults).
Stop seizures with anti-epileptics.
Treat metabolic disturbances.
Lower intracranial pressure.
Treat infections.
Mechanical ventilation, IV lines and Ryles tubes.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Specific Management
Further management depends on the cause always.
Diabetes, hepatic coma, electrolyte imbalances, endocrine
causes etc: Correction of metabolic derangements.
Trauma: Neurosurgery.
Strokes, heart attacks, respiratory failure, hypoxia,
hypothermia: Correct underlying causes.
Medication/drug overdose: Specific antidotes.
Meningitis and infections: Antibiotics.
Raised ICP: Mannitol and Dexamethasone.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Long-term Management
Intensive nursing care.
Recovery position.
Mechanical ventilation.
Pressure sores prevention.
Care of the eyes.
Airway clearance by bronchial toilet.
Fluid and nutrition.
Catheterization of bladder.
Bowel care Disposable diapers.
Physio to protect muscles and joints.
DVT prophylaxis?
Vital signs monitoring.
Neurological monitoring.
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

WORST PROGNOSIS:
Structural damage
Subarachnoid Hemorrhage
Cerebrovascular causes
On Day I:
No corneal reflex
No pupillary reflex
Decerebrate posture

Thursday, August 1
3, 2015

GOOD PROGNOSIS:
Metabolic causes.
If no recovery in 4 weeks
progresses to PVS.
INDICATORS OF PROGNOSIS:
Depth of coma as by GCS
Pupillary reflexes.
Eye movements.
Motor responses.
Age.

Dr. Raj Gopal. V

Complications

Pressure sores.
Bladder infections.
Pneumonia: Hospital acquired or ventilator
associated.
Persistent Vegetative State.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Persistent Vegetative State

A note on PVS
Permanent condition that emerges after severe brain injury.
Normal sleep-wake cycles and eyes that open to verbal
stimuli.
No cognitive function.
Cannot localize pain, or follow verbal commands.
Blood pressure and respiration maintained.
Synonyms: Coma vigil, Cerebral death, Total dementia.
Very slim chances that the individual might recover.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Brain death
Brain death is different from coma and PVS
Complete lack of activity anywhere in the brain.
Kept alive through artificial means.
Clinically and legally dead.
Confirmatory EEG for legal purposes: Isoelectric flat line.
Tests: Shine a light into eyes, corneal reflex, pain
sensation, caloric tests, gag or cough reflex tested and
removal from ventilator for short period to see if it stimulates
respiration.
Organs for transplantation if there is consent.

Thursday, August 1
3, 2015

Dr. Raj Gopal. V

SUMMARY
Quick history from relatives and friends.
Quick medical examination.
Immediate transfer to specialized centers.
Assessment of Coma depth.
Detailed neurological evaluation.
Basic Laboratory investigations.
Specialized investigations.
Correct underlying cause where possible.
Refer for specialist care if required.
Ongoing care of the patient.
Recovery --------- Congratulations!
Progression to PVS or brain death.
Thursday, August 1
3, 2015

Dr. Raj Gopal. V

Thursday, August 1
3, 2015