Professional Documents
Culture Documents
and Major
Causes of Coma
STRUCTURAL BRAIN INJURY
Hemisphere
Unilateral (with displacement)
Intraparenchymal hematoma
Middle cerebral artery (MCA) occlusion with
swelling
Hemorrhagic contusion
Cerebral abscess
Brain tumor
STRUCTURAL BRAIN INJURY
Bilateral
Penetrating traumatic injury
Multiple traumatic brain contusions
Lymphoma
Gliomatosis
Cerebral edema
Acute hydrocephalus
Leukoencephalopathy (chemotherapy or
radiation)
STRUCTURAL BRAIN INJURY
Brainstem
Pontine hemorrhage
Basilar artery occlusion
Hypothermia
Gas inhalation
Basilar migraine
Malingering
Diagnostic
Workup of
Comatose
Patient
LABORATORY STUDIES CAUSE OF COMA
Glucose Hypoglycemia
Nonketotic hyperglycemia
Diabetic ketoacidosis
Complete blood count Sepsis
Urinalysis Urosepsis
Natrium Hyponatremia
Hypernatremia
Calcium Hypercalcemia
Hypocalcemia
Magnesium Hypermagnesemia
Liver function tests Hyperbilirubinemia
Hyperammonemia
Renal function tests Acute uremia
Thyroid function tests Acute hypothyroidism
Urine toxicology screen Intoxication
Arterial blood gas analysis Hypoxia
Hypercapnia
Lactate Lactic acidosis
Physical Examination for Coma
Treatment
1. Airway, breathing, and circulation – initial resuscitation
2. Respiration – upper and lower airway dysfunction
3. Overall level of consciousness
4. Cranial nerve examination: eye movements; pupillary
responses; oculocephalic and vestibuloocular reflex;
corneal, cough and gag reflex
5. Motor examination: resting posture, spontaneous
motor activity, response to stimulation
6. Systemic examination: temperature; funduscopic;
ear,nose, and throat; integument; cardiac and
vascular; abdomen
Clinical Features with
Special Significance
FINDING SIGNIFICANCE
ODORS
Musty Uremia
Fruity Ketoacidosis
Fishy Hepatic failure
SKIN LESIONS
Bullae, blister Barbiturate overdose
Rash, purpura, petechiae Meningitis, DIC, sepsis, endocarditis
Maculopapular rash Viral meningocephalitis, endocarditis, fungal infection
Vesicular rash Herpes simplex virus or varicella infection
Needle track marks Intravenous drug abuse
Wet skin Cholinergic overdose
Dry skin Anticholinergic overdose
Ecchymosis, petechiae Trauma, steroids, liver disease, anticoagulants, DIC, TTP
Hyperpigmentation Addison’s disease, porphyria, malignant melanoma, chemotherapy
FINDING SIGNIFICANCE
FUNDAL EXAMINATION
Retinopathy Hypertention, diabetes
Papilledema Raised intracranial pressure, hypertensive
retinopathy, carbon dioxide retention
Subhyaloid hemorrhage Subarachnoid hemorrhage
ENT EXAMINATION
Otorrhea, hemotympanum, mastoid or Basal skull fracture
periorbital
Glasgow Coma Scale
SCORE
EYE OPENING
Spontaneous 4
To speech 3
To pain 2
None 1
BEST MOTOR RESPONSE
Obeys 6
Localizes to pain 5
Withdraws to pain 4
Flexor (decorticate) 3
Extensor (decerebrate) 2
None 1
BEST VERBAL RESPONSE
Oriented 5
Confused 4
Inappropriate 3
Incomprehensible 2
None 1
Other Investigations
STUDY INDICATION
Computed tomography (CT) Almost any unconscious patient, especially with focal signs
brain scan
Lumbar puncture Suspected meningitis, encephalitis, or occult subarachnoid
hemorrhage
Angiogram Suspected basilar artery thrombosis
Electroencephalogram Suspected nonconvulsive status epilepticus and for monitoring
of patient’s seizures during treatment
Magnetic resonance imaging Suspected cerebral venous sinus thrombosis, basilar artery
or magnetic resonance occlusion, cerebellar or brainstem infarction not well visualized
venography (MRV) on CT; adjunctive test for herpes simplex encephalitis