APPROACH TO

COMATOSE PATIENT

Nurul Izzah Binti Ariffin

 Definition
Coma is a state of profound unrousable unresponsiveness in which the
patient lies with their eyes closed and does not respond appropriately to
external or internal stimuli.

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 Level of arousal (conciousness)
▪ Conscious: alert, attentive and cooperative, awareness of self and environment
▪ Confused: conscious but tallks irrelevantly
▪ Drowsy: sleepy but can be aroused easily by external stimuli
▪ Stupor: Deep sleep, can only be aroused by painful stimulus
▪ Coma: unconsious, no response to external stimuli

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 Approach to comatose patient
1. Immediate assessment and management
Urgently address compromised
2. Check airway, breathing and circulation (ABC) identified in ABC
• Seek help from critical care
3. Immobilise cervical spine if traumatic injury possible
• Commence supportive measures
4. Measure capilary glucose
• Treat hypoglycemia with
5. Check pupil size and reactivity intravenous glucose
• Treat suspected opoid toxicity
6. Calculate glasgow coma scale (GCS) with intavenous naloxone

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 HISTORY TAKING
➢ Collateral history from relatives or witnesses, including paramedics
➢ Onset of coma? (abrupt- suggest a vascular disorder; or gradual- suggest a
metabolic disorder evolving intracranial mass)
➢ Prodromal symptoms? Headache, pyrexia, systemic illness, depression, ataxia, neck
stiffness, photophobia, vertigo, focal weakness, seizures
➢ Recent head injury?
➢ Medical history including drug history? (e.g diabetes, renal failure, ischaemic heart
disease, epilepsy)
➢ Psychiatric history? (Including prior suicide attempts, alcohol or drug abuse)
➢ Was there an empty pill or alcohol bottles around the patient? - suggest intoxication

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 HISTORY TAKING
➢ Has the patient in the past similar to current events?
➢ Had the patient complained of headache or fever prior to the event?- suggest an
infectious etiology
➢ Was there any confusion or difficulties with speech or language in the preceeding
days?

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 GENERAL EXAMINATION
✓ Check vital signs:
• Pulse: braydcardia or tachycardia
• Blood pressure: high- hypertensive encephalopathy; low- Addisonian
crisis,alcohol, barbiturates, MI, sepsis
• Temperature: Fever in sepsis, meningitis, encephalitis, heat stroke,
anticholinergic drug intoxication; Hypothermia in alcohol, baribiturates, sedative
intoxications, hypoglycemia
• Respiratory: Cheyne-Strokes Respiration- alternating hypercapnoea &
periods of apnea;indicates bilateral cerebral or upper brainstem dysfunction;
Acidotic (Kussmaul ) Respiration- Deep, rapid breathing pattern or
hyperventilation & seen in diabetic ketoacidosis

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RESPIRATORY PATTERNS

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 GENERAL EXAMINATION
✓ Skin
• Injuries, bruises: traumatic causes
• Cyanosis
• Jaundice
• Purpura
• Pigmentation
• Dry skin: DKA, atropine
• Moist skin: Hypoglycemic coma
• Cherry-red: CO poisoning
• Needle marks: drug addiction
• Rashes: meningitis, endocarditis

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 GENERAL EXAMINATION
✓ Odour of breath
• Acetone: DKA
• Fetor hepaticus: in hepatic coma
• Urine ferous: in uremic coma
• Alcohol odour: in alcoholic intoxication

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NEUROLOGICAL
EXAMINATION

• Assess the level of

consciousness
• Glasgow coma scale (GCS):
GCS < 8 indicates coma
• Mild: 13-15
• Moderate: 9-12
• Severe: 3-8

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 • Eye movements cannot be fully assessed in unconscoius patients
• Doll’s eyes or oculocephalic reflex can be performed (if there is no neck
injury)

o Positive doll's eye reflex (eyes move in opposite direction of head

movement) indicates an intact brainstem.
o Negative doll's eye reflex (eyes remain midline or move in same direction of
head movement) indicates severe brain stem dysfunction.

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 PUPILS EXAMINATION
• Small pupils (<2 mm) – opioid toxicity or a pontine lesion
• Midsize pupils (4–6 mm) unresponsive to light – midbrain lesion
• Maximally dilated pupils (>8 mm) – drug toxicity, eg anticholinergic overdose
• Mixed and dilated pupil(s) – 3rd (oculomotor) nerve lesion from uncal herniation.

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 Conjugate gaze deviation
• Eyes may deviate horizontally toward a cortical lesion
• Eyes may away from a pontine lesion & away from a cortical seizure focus

Common ipsilateral gaze deviations

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 Fundoscopy

• Papilloedema in posterior
• subhyaloid haemorrhage in
reversible encephalopathy
subarachnoid haemorrhage.
syndrome (PRES)

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 Signs of lateralizations
• Unequal pupils
• Deviation of the eyes to one side
• Facial asymmetry
• Turning of head to one side
• Unilateral hypo-hypertonia
• Asymmetric deep reflexes
• Unilateral extensor plantar response (Babinski)
• Unilateral focal

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 INVESTIGATIONS
• Assessment of severity and ongoing care

o Full blood count

o Blood glucose – even if the capillary blood glucose is normal
o Urea and electrolytes
o Calcium and bone profile
o Liver function tests
o Clotting screen
o Toxicology screen – including paracetamol, salicylate and blood alcohol level
o Electrocardiogram (ECG)
o Chest X-ray
o Arterial blood gas – including carbon monoxide concentration
o Blood cultures should be taken from patients with fever or suspected sepsis,
preferably before the administration of empirical antibiotics
o Other microbiology samples should be taken based on the clinical assessment

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 INVESTIGATIONS
• Urgent imaging of brain is important (if the cause of unconsciousness is not obvious)
• Computed tomography (CT scan): to exclude intracranial blood, stroke or space
occupying lesion
• MRI may be required (if the CT scan is normal & diagnosis remains unclear
• Lumbar puncture (if no contraindication)
• Electroencephalography (EEG): suspected cases of non-convulsive status
epilepticus (prolonged seizure but absence motor signs; common in older patients,
stare into space with nystagmus-like eye movements, lip smacking or myoclonic jerks)

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 Management & Treatment
As the ABC assessment is undertaken, other team members should be:
• taking blood tests
• establishing intravenous access
• connecting the patient to a cardiac monitor and oxygen saturation probe
• commencing appropriate oxygen therapy if indicated.

➢ Patient with suspected increased ICP:position the patient in 30 degree head tilt
➢ Opiote toxicity: naloxone
➢ Hypoglycemia: IV glucose
➢ Excessive alcohol intake: Thiamine
➢ Benzodiazepines overdose: Flumazenil (contraindicates in patients with hx of
seizures & can provoke seizures with concomitant tricyclic overdose)

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Thank You