Approach to comatose patient

Abyot
B5 Female side
የህዝብ በህዝብ ለህዝብ
 Outline
Definition of terms
GCS
CAUSE
APPROACH
REFERENCE
 What is consciousness?
• There are two aspects of conscious behavior:
Arousal
Awareness
• Consciousness requires:
- an intact reticular activating system
- an intact cerebral hemisphere
 Levels of Consciousness
Lethargy: simulates light sleep
Obtundation : requires touch or voice to
maintain arousal.
Stupor: unresponsiveness from which the
individual can be aroused only by painful
stimulus
Coma: State in which the patient is unable to
arouse or respond to noxious stimuli and is
completely unaware of self and surroundings
unawareness and
loss of wakefulness
 Conditions Simulating coma
1. Vegetative state : (Coma Vigil) ‘‘Awake Coma ’’ signifies an
awake but unresponsive state.
2. Locked-in-state: awake but communicates with eye
movements. ventral pons.
3. Akinetic Mutism: form impression and think.medial
thalamic nuclei or the frontal lobes or from extreme
hydrocephalus.
4. Abulia : mental and physical slowness and diminished ability
to initiate activity.
5. Catatonia: hypomobile and mute syndrome that occurs as
part of a major psychosis, usually schizophrenia or major
depression.
 Glasgow coma Score
• Eye opening Motor Response
– Spontaneous 4 obeys commands 6
– To command 3 localizes pain 5
– To pain 2 withdraws to pain 4
– None 1 abnormal flexion 3
• Verbal abnormal extension 2
– Oriented 5 none 1
– Confused 4
– Inappropriate words 3 TOTAL 3-15
– Incomprehensible sounds 2
– None 1
GCS of 13-15 indicates mild head injury, GCS of 9-12 indicates
moderate head injury and GCS <8 indicates severe head injury.
 Cause coma
- Brainstem
- Cerebral hemispheres
- Unilateral cerebral lesions : compress or injure
contralateral or brainstem structures
 Causes of coma
1) Metabolic
• Hypoglycemia
• Diabetes Mellitus
• Renal failure
• Hepatic failure
• Hypothermia
• Hypothyroidism
• Cardiorespiratory failure
• Hypoxic Encephalopathy
2) Drug overdosage (Opiates, salicylates, organophosphate,
benzodiazepines)
3)Poisoning (Alcohol, recreational drugs, accidental/deliberate
poisoning)

4)Structural – diffuse & focal causes

i) Diffuse
- Meningitis
- Encephalitis
- Other infections e.g. cerebral malaria
- Epilepsy
- Hypertensive encephalopathy
- Subarachnoid hemmorrhage
- Head injury
 ii) Focal

Supratentorial Lesions Infratentorial lesions

• Head injury • Cerebellar hemorrhage

• Cerebral hemorrhage • Cerebellar abscess
• Cerebral infarction with • Pontine hemorrhage
edema • Brainstem infarction
• Subdural hematoma • Tumor e.g. brain stem tumor
• Epidural hematoma • Secondary effects of
• Tumor transtentorial herniation of
• brain due to cerebral mass
Cerebral abscess
lesions
Approach to comatose patient

Hx
PE
LAB
Management
 History of comatose patient
• Onset
-sudden onset- vascular origin
-rapid progression from hemispheric signs – intracranial
hemorrhage
-insidious onset – mass lesion, chronic hematoma
-preceding confusion –metabolic cause
• Fever, chills, sweating –infectious causes
• Neck pain, photophobia - meningitis
• History of trauma
• Travel or living in malaria endemic area
• History of toxin ingestion or drug or toxic material in the house
• History of abnormal body movement
• Past illness
• Previous illness
- Previous attack , HTN , DM , epilepsy , lung
disease , heart disease , uremia , cirrhosis
- Cancer , allergy , infectious disease,
endocrine
disease ,TIA ,Psychiatric diseases
 Reference
• Harrison ,18th edition
• Nelson 18th edition
• Dr Ayalew note Pediatric neurologist
Thank you