COMA

Haytham Eloqayli

COMA
Sleep is unconsciousness from which the person can be aroused by sensory or other stimuli Coma is unconsciousness from which the person cannot be aroused

COMA
Consciousness Is Dependent on an Intact Ascending Reticular Activating System (RAS)
excitatory area located in the reticular substance of the upper mid-pons and mesencephalon Inhibitory area located in the reticular substance of the lower mid-pons and medulla

RAS

RAS

COMA
Assessment of the level of Consciousness A. Neurologic: States of Altered Consciousness B. Neurosurgical: GCS

States of Altered Consciousness

State Lethargy

Description of Patient fatigued with minimal difficulty maintaining alertness moderate reduction in alertness with decreased interest in environment, responsive to stimuli other than pain unresponsiveness with arousal only vigorous/painful stimulus, return to unresponsiveness with removal of stimulus

Obtunded

Stupor to

Glasgow Coma Scale 3-15

Eye Opening Never To pain To verbal Spontaneous

1 2 3 4

Best Verbal Response None 1 Sounds 2 Inapp words 3 disoriented 4 oriented 5

Best Motor Response None 1 Extensor 2 Flexor Posture 3 Withdrawal 4 Localization 5 obeys 6

COMA
      

Common Etiologies of Coma Drug Overdose Metabolic Head Trauma Anoxia Stroke (infarction, bleeding) Status Epilepticus Infectious (bacterial meningitis)

COMA
Drug overdose Narcotics, Tricyclics, Stimulants Metabolic Hypoglycemia Sepsis Hepatic encephalopathy Uremic encephalopathy Hypothyroidism ETOH withdrawal/intoxication

COMA
Initial Management 1.ABC 2.IV line, Pulse oxy., oxygen supply 3.Rapid neurological assessment: level of consciousness, pupils. 4.Lab work up 5.Empirical medical treatment. 6.Specific treatment: according to the pathology 7. Diagnostic tests

COMA
Initial Management A, B, C A: insure patent airways (spontaneous, mouth piece, ETTetc) B: insure breathing and adequate oxygenation (pulse oxy., ABG) C: control any active bleeding and insure adequate circulation (BP, P)- IV line, arterial line, ECGetc)

COMA
Lab work up
fingerstick for glucose (hypoglycemia)
CBC, electrolytes, BUN/Cr, Calcium, ABG, LFTs, ammonia, UA, serum and urine tox screen, blood cultures if febrile

Empirical treatment

Dextrose (1 amp = 25 grams IV push)

Thiamine 100 mg IM (never before Dextrose)

COMA
Specific treatment:
according to the pathology

Examples 1.Hypoglycemia 2.Status epilepticus 3.Head injury 4.Subarachenoid bleeding

COMA
Diagnostic Testing


Non contrast head CT  Acute blood  Space occupying lesion LP  Xanothochromia (SAH)  Infection MRI  Posterior fossa  Early infarct EEG

COMA
-Hypoglycemia: serum glucose level < 50 mg/dL -Causes of hypoglycemia are varied, but it is seen most often in diabetic patients. -Initial Mx: 50 mL of 50% dextrose IV bolus after blood draw

COMA
Status epilepticus:
-Describe any continuing type of seizure -definition: 30 minutes of continuous seizure activity or a
series of seizures without return to full consciousness

MX:
1.ABC 2.Dextrose, Thiamine 3.medical

COMA
Medical:
1.Lorazepam: Adults: 4 mg IV slowly at 2 mg/min; if seizure continues or recurs after 10-15 min, administer an additional 4 mg IV slowly at 2 mg/min Infants and children: 0.1 mg/kg IV slowly over 2-5 min; repeat prn in 10-15 min at 0.05 mg/kg; not to exceed 4 mg/dose 2.Diazepam Adult: 5-10 mg IV q10-20min; repeat in 2-4 h prn; not to exceed 30 mg/8 h Children:0.05-0.3 mg/kg/dose IV over 2-3 min q15-30min; repeat in 2-4 h prn; not to exceed 10 mg

COMA
3.Phenytoin: Both adult and children Loading dose: 18mg/kg IV; hypotension may necessitate slowing administration rate; rate not to exceed 50 mg/min (hypotension and arrhythmias can otherwise occur); if status persists, may increase to total of 30 mg/kg 4. Phenobarbital Adults: Loading dose: 18 mg/kg IV; maximum infusion rate of 100 mg/min Children: Loading dose: 18 mg/kg over 10-15 min IV