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Wednesday, April 7, 2010 Dr. Raj Gopal.

V
Definition of COMA
Coma is defined as a sleeplike state with total absence
of awareness of self and the environment, even after
vigorous external stimulation. Coma is the most severe
form of unresponsiveness, and by definition, comatose
patients lie with their eyes closed. In general a
comatose person is:

•Apparently asleep.
•Closing the eyes.
•Not talking.
•Unresponsive to instructions.
•Without any voluntary movements.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
The various states of consciousness
For consciousness to be intact the cerebral hemispheres must be activated by the Reticular
Activating System in the brainstem.
Conscious Alert and oriented
state
Drowsy Sleepy but can be woken up

Stupor Unconscious but responds to vigorous stimulation

Coma Unconscious and unresponsive
(Never lasts more than 2-4 weeks)

PVS All cognitive functions lost.
(Persistent Maybe awake but totally
Vegetative unresponsive. Breathing, circulation
State) and internal organ functions intact.
May last for years.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Pathophysiology of coma
Primarily 2 mechanisms:

•A diffuse insult to both cerebral hemispheres.
•A focal lesion in the Reticular Activating
System (RAS) in the upper Pons, midbrain or
the Diencephalon.

•The “Big-3” causes: Stroke, Trauma, Drug
overdose (STD!).

Wednesday, April 7, 2010 Dr. Raj Gopal. V
COMA

RAS

(Diencephalon) COMA

Wednesday, April 7, 2010 (Pons,
Dr. Raj Medulla)
Gopal. V
Causes of COMA
Two broad categories: Structural or surgical
and Metabolic or Medical.

Structural/Surgical: Diffuse damage to both cerebral
hemispheres due to vascular damage or raised
intracranial pressure.

Medical/Metabolic: Diffuse insult to both cerebral
hemispheres by toxins, either from within or from
outside.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Causes of COMA
Remember AEIOU-TIPS
A: Alcohol.
E: Epilepsy or Exposure to heat and cold
I: Insulin (Diabetic emergencies)
O: Overdose or Oxygen deficiency
U: Uremia (kidney failure)
T: Trauma (Shock or head injury)
I: Infection or Iatrogenic.
P: Psychosis or poisoning.
S: Strokes.

There are 424 causes of COMA!
Wednesday, April 7, 2010 Dr. Raj Gopal. V
Causes of Surgical or Structural COMA

•Trauma: Subdural/Epidural/Penetrating head injuries,
brain contusions.
•Intracranial Hemorrhage: Subarachnoid or
intracerebral.
•Ischemic Stroke.
•Diffuse microvascular abnormalities like purpura,
Cerebral Malaria, Rocky Mountain Spotted Fever.
•Tumors, either primary brain tumors or metastasis.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Causes of Metabolic or Medical COMA
•Drug overdose: Benzodiazepines, Barbiturates, Opioids,
Anti-depressants.
•Infections: Bacterial meningitis, Encephalitis, Sepsis.
•Endocrine disorders: Diabetic emergencies, Myxedema,
hyperthyroidism.
•Metabolic causes: Hyponatremia, Hypernatremia,
Uraemia, Hypoxia, hepatic coma, Hypertensive
encephalopathy.
•Toxic: Carbon Monoxide poisoning, Alcohol,
Acetaminophen Overdose.
•Medication side effects.
•Hypothermia or hyperthermia.
•Deficiency states: Thiamine (In alcoholics) and Niacin.
Wednesday, April 7, 2010 Dr. Raj Gopal. V
Differences
Differences between Structural or surgical and
Metabolic or Medical.

Structural/Surgical: Focal neurological signs, dilated
and unreactive pupils and increased intracranial
pressure.

Medical/Metabolic: Reactive pupils, no focal
neurological signs and normal intracranial pressures.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Diagnosis of COMA

•History from third parties like family, friends and
emergency medical personnel. Ask relevant
questions.
•Clinical Examination: Quick and precise.
•Rapid and appropriate investigations: To find cause
and institute appropriate treatment.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Assessment of COMA
The level of coma is assessed by the Glasgow
Coma Scale. A quick assessment is the AVPU
scale, used by emergency medical personnel:

•A: Alert.
•V: Responds to verbal commands.
•P: Responds to pain.
•U: Unresponsive - - - - - Proceed to GCS.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Assessment of COMA

The level of coma is assessed by the Glasgow
Coma Scale. GCS assesses:

•Best verbal response.
•Best motor response.
•Level of stimulus needed to make the patient
open the eyes.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
The Glasgow Coma Scale
EYE OPENING MOTOR RESPONSE
Spontaneous 4 Obeys 6
To speech 3 Localizes 5
To pain 2 Withdraws 4
No response 1 Abnormal flexion 3
Extension Posturing 2
No response 1

VERBAL RESPONSE
Oriented 5 Total score: E + M + V
Confused conversation 4 Range: 3 – 15.
Inappropriate words 3 Mild coma: 13 – 15
Incomprehensible sounds 2
Moderate coma: 9 – 12
No response 1
Severe coma: < 8

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Examination of a Comatose patient

•Baseline: HR, BP, Rectal temperature, Oxygen saturation
and capillary Glucose.
•Response to external stimuli: None.
•Signs of trauma.
•Skin and mucus membranes survey: hyperpigmentation,
cherry red color, anaemia, jaundice, rashes, IV drug abuse
sites, myxoedema.
•Any MedicAlert bracelets or cards?
•Breath smell: Ketones, alcohol, Solvents.
•Examine RS, CVS, PA.
•Neurological examination including meningeal signs.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Neurological examination

The neurological examination focuses on 4
components.
•Respiratory patterns.
•Pupillary responses.
•Eye movements.
•Motor responses.

The most important examination in coma (to identify the
cause) is the examination of the pupillary response
and eye movements.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Respiratory patterns
Pattern Lesion Description

Cheyne-Stokes Forebrain to Hyperventilation and
pons hypoventilation with pauses.
Central Neurogenic Midbrain to Rapid, deep breathing
Hyperventilation pons

Apneustic breathing Pons Prolonged inspiratory gasp followed
by a pause and then expiration
Cluster breathing High medullary Periodic breathing with irregular frequency
lesions and amplitude, along with variable pauses

Ataxic breathing Medulla Irregular in rate and rhythm

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Pupillary responses

•Most important part of examination.
•Pupils that react to light and are equal in size: Metabolic or
medical coma.
•Unreactive, unequal and dilated pupil: Neurosurgical
emergency.
•Pinpoint pupils: Pontine lesions or opiate toxicity.
•Bilateral dilated, unresponsive pupils: Anoxia, severe
midbrain damage or anticholinergic drugs.
•No pupillary abnormality: Excludes lesions below pons
and above thalamus.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Eye movements
•Roving, slow, conjugate, lateral to and fro movements: Metabolic
encephalopathies or bilateral lesions above brainstem.
•Ocular bobbing: Rapid downward jerk and slow return to
midposition of both eyes: Bilateral pontine lesions.
•Ocular dipping: Slow downward dipping followed by brisk return:
Diffuse cerebral damage.
•Skew deviation in horizontal plane; Cerebellar or pontine lesion.
•Doll’s eye reflex: Normally when the head is turned in a lateral
plane the eyes move in the opposite direction. Absence of this
response indicates brainstem lesion.
•Caloric testing: 40-60 mL of ice cold water in the ears will cause
the eyes to move towards the irrigated ear. Absence indicates
brainstem damage.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Motor responses

•Spontaneous movements always good sign.
•One side paralyzed: Suspect lesion in brain on the side
not moving.
•Decorticate posturing: Arms flexed and legs extended
indicates lesions above brainstem or a metabolic cause.
•Decerebrate posturing; Arms extended and legs extended
indicates bilateral midbrain or pontine lesion. Worse
prognosis. Also seen in metabolic conditions sometimes.
•Myoclonus: Non-rhythmic jerking in single or multiple
muscle groups suggests metabolic encephalopathies
(hepatic chiefly).

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Investigations
•Full blood counts: Infections.
•Biochemistry: Electrolytes, sugar, LFTs, KFTs.
•Arterial blood gases: Oxygen, CO2, pH, HCO3.
•Blood cultures.
•Alcohol levels.
•Drug screen (urine and blood)
•Lumbar puncture: Infections.
•CT Scans in case of trauma, bleeds, hemorrhage.
•MRIs where possible.
•Thyroid function tests (rarely)
•Electroencephalogram (EEG) & ECG.
•CXR.
•Blood slides for Malaria!!
Wednesday, April 7, 2010 Dr. Raj Gopal. V
Management

Immediate management in hospital:
•Never forget ABC: Airway, Breathing, Circulation.
•“COMA COCKTAIL”: 50 mL of 50% Dextrose + Thiamine
100 mg + Naloxone 0.4 mg (adults).
•Stop seizures with anti-epileptics.
•Treat metabolic disturbances.
•Lower intracranial pressure.
•Treat infections.
•Mechanical ventilation, IV lines and Ryle’s tubes.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Specific Management

Further management depends on the cause always.
•Diabetes, hepatic coma, electrolyte imbalances, endocrine
causes etc: Correction of metabolic derangements.
•Trauma: Neurosurgery.
•Strokes, heart attacks, respiratory failure, hypoxia,
hypothermia: Correct underlying causes.
•Medication/drug overdose: Specific antidotes.
•Meningitis and infections: Antibiotics.
•Raised ICP: Mannitol and Dexamethasone.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Long-term Management
•Intensive nursing care.
•Recovery position.
•Mechanical ventilation.
•Pressure sores prevention.
•Care of the eyes.
•Airway clearance by bronchial toilet.
•Fluid and nutrition.
•Catheterization of bladder.
•Bowel care – Disposable diapers.
•Physio to protect muscles and joints.
•DVT prophylaxis?
•Vital signs monitoring.
•Neurological monitoring.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
GOOD PROGNOSIS:
WORST PROGNOSIS: Metabolic causes.
Structural damage If no recovery in 4 weeks
Subarachnoid Hemorrhage progresses to PVS.
Cerebrovascular causes
INDICATORS OF PROGNOSIS:
On Day I: Depth of coma as by GCS
No corneal reflex Pupillary reflexes.
No pupillary reflex Eye movements.
Decerebrate posture Motor responses.
Age.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Complications

•Pressure sores.
•Bladder infections.
•Pneumonia: Hospital acquired or ventilator
associated.
•Persistent Vegetative State.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Persistent Vegetative State
A note on PVS
•Permanent condition that emerges after severe brain injury.
•Normal sleep-wake cycles and eyes that open to verbal
stimuli.
•No cognitive function.
•Cannot localize pain, or follow verbal commands.
•Blood pressure and respiration maintained.
•Synonyms: Coma vigil, Cerebral death, Total dementia.
•Very slim chances that the individual might recover.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Brain death
Brain death is different from coma and PVS
•Complete lack of activity anywhere in the brain.
•Kept alive through artificial means.
•Clinically and legally dead.
•Confirmatory EEG for legal purposes: Isoelectric ‘flat’ line.
•Tests: Shine a light into eyes, corneal reflex, pain
sensation, caloric tests, gag or cough reflex tested and
removal from ventilator for short period to see if it stimulates
respiration.
•Organs for transplantation if there is consent.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
SUMMARY
•Quick history from relatives and friends.
•Quick medical examination.
•Immediate transfer to specialized centers.
•Assessment of Coma depth.
•Detailed neurological evaluation.
•Basic Laboratory investigations.
•Specialized investigations.
•Correct underlying cause where possible.
•Refer for specialist care if required.
•Ongoing care of the patient.
•Recovery --------- Congratulations!
•Progression to PVS or brain death.

Wednesday, April 7, 2010 Dr. Raj Gopal. V
Wednesday, April 7, 2010 Dr. Raj Gopal. V