HOW TO APPROACH TO

COMATOES PATIENT
 CONSCIOUSNESS
 State of awareness of self and environment with the
ability to respond appropriately to stimuli result from:
 Arousal (ascending reticular activating system (RAS)
 Awareness (cerebral cortex)
A) COMA:
 State of unrousable unconsciousness due to damage to the RAS in the brain
stem or extensive bilateral cortical damage.

B) LETHARGY:
 Mild reduction in alertness.

C) STUPOR:
 Deep sleep, patient can be aroused only by vigourous and repetitive
stimulation, return to deep sleep when not continually stimulated.

D) PVS:
 Persistent vegetative state (PVS) is the disorder of consciousness in which
patients with severe brain damage are in a state of partial arousal rather than
true awareness.
 CLASSIFICATION OF COMA
1) COMA WITHOUT FOCAL SIGNS OR MENIMGISM
• Hypoxic ischemic injury
• Metabolic
• Toxic
• Post ictal

2) COMA WITH MENINGISM

• Meningitis
• Sub arachnoids hemorrhage
3) COMA WITH FOCAL SIGNS
• Hemorrhage
• Infarction
• Abscess
• Tumor
• Hypoglycemia
 CAUSES OF COMA
A) CEREBRAL AND INTRACRANIAL DISORDERS
• Traumatic brain injury
• Vascular brain injury
• Infections
• Hydrocephalus
• Raised Intracranial pressure
• Status epileptics
• Hypoxic damage
• Malignancy
 CONT….
• Medication overdose (opioids, barbiturates, SSRI)
• Drugs of abuse (alcohol, cocaine, amphetamine )
• Carbon monoxide poisoning
• Hypothermia / Heat Stroke
• Hepatic failure / renal failure / cardiac failure
• Electrolytes imbalance (hyponateremia,
hypernateremia, hypoglycemia, hyperglycemia)
• Endocrine Disorder (panhypopitutarism, Adrenal
insufficiency)
 GENERAL ASSESSMENT OF COMA

A) HISTORY
• Obtain from relative, eye witness.
• Drug overdose, Trauma, insect bite.
• Fever
• Onset (static, recovery)
• Psychiatric illness.
• Exposure to not environment.
• Risk factors (HTN, DM, Smoking)
• Fits (tongue bite, urinary incontinence )
• Exposure to pesticides
 B) GENERAL PHYSICAL EXAMINATIONS
I) Temperature (infection, Heat stroke, Malignant Hyperthermia)

II) Temperature (Drugs, neuropathy, Sepsis, uremia)

III) Pulse rate (Anemia, cardiac disease, Hypotension)

IV) Pulse rate (raise intracranial pressure, Heart block)

V) Blood pressure (Hypertension, raise icp)

VI) Blood pressure (Shock)

 VII) RESPIRATION
• Slow shallow breath (Drug intoxication)
• Deep rapid respiration (metabolic acidosis)
• Periodic respiration (cardiac failure, brainstem lesion)
• Rapid shallow respiration (Kato acidosis)
VIII)

IX)
Breath odor (alcohol, ketoses, hepatic/renal failure)
X) Cyanosis (respiratory failure)
XI) Anemia (blood loss, chronic discord)
XII) Edema (renal failure, heart failure, hepatic failure)
XIII)
Skin Lesions (rash, needle mork, pigmentation)
Lymph adenopathy (Tuberculosis, malignancy)
NEUROGICAL EXAMINATION
CONSCIOUS UNCONSCIOUS
• Higher mental function • GCS
• Cranial nerves • Pupil
• Motor examination • Eye deviation
• GAIT Assessment • Fundoscopy
• Sensory examination • Corneal reflex
• Cerebellar examination • Facial asymmetry
• Dorsal Colum • Motor examination
• SOMI • SOMI
 NEUROLOGICAL ASSESSMENT
I. Assessment of consciousness
- Glasgow coma scale
II. Check for meningism (meningitis SAH)
III. Fundoscopy (pappiloedemo, subhyloid hemorrhage retinopathy)
IV. Examination of pupil
- unilateral fixed dilated pupil (3rd nerve palsy)
- Bilateral fixed dilated pupil (brainstem damage)
- Midpoint fixed pupil = (midbrain leaser)
- Small pinpoint pupil = (puns leaser)
- Small reactive pupil = (lesion in thalamus)
V. Eye deviation
- conjugate lateral deviation (ipsilateral frontal lobe or brainstem leaser)
- Dysconjugate eyes (3rd, 4th or 6th nerve palsy)
 CONT….
VI. Corneal reflex (Loss in brain death)
VII. Facial asymmetry (7th nerve palsy)
VIII. Motor examination (Bulk, tone, reflex)
A. Abdomen Examination (Hepatomegaly, Splenomegally
Lymphadenopathy)
B. Cardiac examination
C. Respiratory examination
 SUBARACHNOID HEMORRHAGE
 Causes = rupture berry aneurysm, Trauma, warfare overdose
 Clinical features
Headache (Severe + Sudden)
Vomiting
Alco
neck stiffness +ve
 Investigation
1. CT scan brain (plain) Abnormal 95% cases in 24hrs
2. Lumbar puncture
3. CT Angiography
 CONT….
 Management
1. Bed rest
2. Treat raised ICP (mannitol)
3. Analgesics
4. Treat cerebral vasospasm (calcium channel blocker)
5. Surgery
 STATUS EPILEPTICUS
DEFINITION:
 Single epileptic seizure lasting more than five minutes.
 OR
 Two or more seizures within a five minutes period without the person
returning to normal between team.

 Risk factors
• Febrile illness
• CNS infection
• Toxicity
• SOL

 Mortality - 20%
 CONT….
 Complications:
1. Increase ICP
2. Hypoxic brain injury
3. Hypertension / hypotension
4. Cardiac arrhythmias
5. Cardiogenic shock
6. Aspiration pneumonia
7. Pulmonary embolism
8. Respiratory failure
9. Dehydration
10. Rhebdomyolysis
I nvestigation
• Blood CP, U/C/E, RBS
• CT scan brain
• Electroencephalography (EEG)
• CSF DR

 Management

1. Maintain airway breathing circulation

2. Intravenous Diazepam or Lorazepam
3. I V phenytoin (15- 18mg / kg)
if still fits occur
4. I V anesthetic agents (midazolam , propofol)
5. Treat infection (ē i/v antibiotic)
INVESTIGATIONS(UNCONCIOUS PATIENT)
• Blood CP
• ESR
• Urea / creative
• Serum electrolytes, calcium, Mg+
• Blood sugar
• Drug level (carbomozipive, valproid acid)
• Lumbar puncture
• Blood test for alcohol level, toxin level
• CXR
• Urine DR
• ECG , 24 hrs halter monitoring
• Electroencephalography (EEG)
• Neuroimaging (CT scan brain / MR I Brain)
MANAGEMENT OF COMATOES
PATIENT
1. Identity and treat cause
2. Stabilize neck movements ē cervical collar.
• If suspected traumatic cervical injury.
3. Pass nasogastric tube
4. Urinary catheterization
5. Oxygen therapy
INDICATIONS:-
◦ Hypoxia (Oxygen saturation <92%)
◦ Acute and chronic hypoxemia
◦ Signs and symptoms of shock
6. ENDOTRACHEAL INTUBATION
INDICATIONS
 Inability to maintain airway patency
 Inability to protect the airway against aspiration
 Failure to ventilate
 Failure to oxygenate

7. MECHANICAL VENTILATION
INDICATIONS
 Apnea with respiratory arrest
 Acute lung injury
 Tachypnea
 Vital capacity less than 15ml/kg.
8. IV FLUID
◦ Dehydration hypovalumic shock
9. IONOTROPIC AGENTS
◦ Cardiogenic shock
10. ANTIBIOTICS
◦ Systemic / CNS infection
11. Antipyretics
12. I/V Dextrose (glucose)
◦ Hypoglycemic shock
13. Correct electrolytes imbalance
14. Antiepileptic drugs
15. Steroids
16. Treat raised intracranial pressure
◦ Head end elevate 45
◦ Steroids
◦ Osmotic therapy (I/V Mannitol)
17. IV antihypertensive therapy
◦ Hypertensive encephalopathy
18. Antidote therapy
◦ I/V nalaxone (OPOIDS Poisoning)
◦ I/V Flumazenil (Benzodiazipine)
◦ I/V atropine (Organophosphate poisoning)
◦ Pralidoxime (Organophosphate poisoning)
19. Subcutaneous Heparin
◦ Prophylactic therapy for DVT
20. Frequent posture change
◦ Avoid bedsores
21. Physiotherapy
22. Surgery
INDICATIONS:-
◦ Cerebellar bleed
◦ Intraventricular bleed
◦ Subarchnoid hemorrhage
◦ Massive cerebral infarction
◦ Brain tumor
 THANKYOU