Neurological Coma

Zainuddin Arpandy, Sp.S

Neurology Department of Ulin
Hospital Banjarmasin
 Consciousness
Consciousness is an active process requiring intact
cerebral hemispheres and a functioning ascending
reticular activating system (ARAS).1

1. Patel S, Hirsch N. Coma. Continuing Education in Anaesthesia, Critical Care & Pain. 2013 Nov 19;14(5):220-3.
 Coma
• Coma is a state of unarousable and unresponsiveness. 1,2
• patient lies with the eye closed and has no awareness of self and
surroundings.2

• due to bilateral hemispheric damage, brainstem dysfunction that

disrupts the ARAS, or both.1
1. Patel S, Hirsch N. Coma. Continuing Education in Anaesthesia, Critical Care & Pain. 2013 Nov 19;14(5):220-3.
2. Tindall SC. Level of consciousness dalam Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.
Emory University School of Medicine.1990.
 Level of Consciousness

Coma  GCS E1V1M1

Classification of Coma (Based on its etiology).1

Neurological coma
Diffuse physiological brain
dysfunction
COMA
Psychiatric

metabolic

1. Cooksley T, Holland M. The management of coma. Elsevier. 2017.

 Differential
diagnosis of
coma.1

1. Cooksley T, Holland M. The

management of coma.
Elsevier. 2017.
How to diagnose neurological coma ?

Anamnesis  history before patient get unconscious

 finding possible etiology

Physical examination
- GCS (Glasglow Coma Scale)
- General Examination
- Neurological Examination

Supportive examination
- CT scan of head
- Laboratory test
 Anamnesis  CEMENITE
C  Circulation : Stroke, cardiac disease

E  Encephalitis : Infection, Sepsis

M  Metabolic : Hyperglycemia, Hypoxia, Uremia, Coma Hepaticum

E  Electrolyte : Diarrhea, Vomiting

N  Neoplasma : Primary Brain Tumor / metastasis

I  Intoxication : Drugs, Alcohol, Chemicals

T  Trauma

E  Epilepsy
 Onset of Unconsciousness

• Cerebrovascular disease
• Encephalitis
Acute • Hydrocephalus obstructive
• Head Trauma

Chronic/ • Metabolic disorder

• Cerebral Edema
• Brain Tumor
Progressive • Brain Abcess
 General Examination
 Vital Sign
 Respiratory Pattern
 Head to toe examination
Respiratory Pattern
 Neurologic Examination
Abnormal Posturing
Pupillary Reflex
• Pupil size,
symmetrically,
and eye position
 Corneal Reflex

Corneal reflex (-) 

trigeminal nerve lesion
Brain stem reflex

DOLL’S EYE MOVEMENT (+)

DOLL’S EYE MOVEMENT (-)

 Meningeal Sign
• Neck stiffness
• Brudzinski I-IV
• Kernig sign
Physiologic Reflex
Pathologic Reflex
Motoric and Sensory Test
 The
management
of unconscious
patient
 Specific Treatment
• Specific treatment is depend on its etiology
• Consult to the neurosurgeon if surgery is needed
• If bacterial meningitis is suspected, empirical antibiotic
treatment should be commenced
• If encephalitis is suspected, IV aciclovir should be given
as soon as possible