COMA – Lecture series 16/07/2016
Consciousness is a state of wakefulness and awareness of oneself, which is controlled by the
central reticular formation in the brainstem When consciousness is reduced, patients show less
wakefulness and a reduced response to stimuli
Therefore Coma is defined as severe impairment of consciousness, when the patient is in a state
of unresponsiveness from which they cannot be roused.
It is a medical emergency that needs rapid assessment and treatment,
CAUSES OF COMA
Extracranial disorders
Generalized disorders such as hypoxia, hypoglycaemia and sepsis can cause diffuse brain
dysfunction
Intracranial disorders
These may cause coma through three mechanisms
1. Diffuse brain dysfunction (such as encephalitis)
2. Brain stem dysfunction which directly affects the reticular formation (such as a pontine
haemorrhage)
3. A supratentorial mass lesion may cause compression or damage to the ascending reticular
activating system.
Extra cranial causes of coma
1. Respiratory insufficiency
Hypoxia
Hypercapnia (carbon dioxide retention)
Severe anaemia
2. Insufficient cardiac output
Hypotension from any cause, such as septic shock, blood loss, myocardial infarction or
cardiac arrhythmia
3. Toxins
Drug overdose
Alcohol
Carbon monoxide poisoning
Organophosphate poisoning
4. Hypertension
Hypertensive encephalopathy
Eclampsia
5. Metabolic causes
Hypoglycaemia
Hyperglycaemia and diabetic ketoacidosis
Renal failure
Hepatic encephalopathy
Lactic acidosis due to sepsis
Hyponatraemia and Hypernatraemia
Hypocalcaemia and Hypercalcaemia
6. Endocrine causes
Hypoadrenalism
Hypopituitarism
Hypothyroidism
Intracranial causes of coma
1. Diffuse brain dysfunction
• Cerebral malaria
• Encephalitis
• Trypanosomiasis
• Meningitis
• Trauma
• Subarachnoid haemorrhage
• Epilepsy
2. Indirect effect on the brain stem
A mass lesion above the tentorium can compress or damage the ascending reticular activating
system eg Hemisphere tumour, infarction, abscess, haemorrhage
3. Brain stem dysfunction
Brain stem haemorrhage
Brain stem infarction
Brain stem tumour
Wernicke’s
Trauma
These can all cause direct damage to the reticular activating system.
Other terms
Persistent vegetative state. This is a state of severe unconsciousness. The person is unaware
of his or her surroundings and incapable of voluntary movement. A vegetative state is diagnosed
after 1 month in a patient without detectable awareness of the environment. A vegetative state is
called persistent after 3 months if the brain injury was medical and after 12 months if it was
traumatic. The determination that persistent equals permanent cannot be stated absolutely;
prediction of which patients will become persistently vegetative early in the vegetative state is
particularly difficult in cases of trauma.
Locked-in syndrome. This is a rare neurological condition. The person is totally paralyzed
except for the eye muscles, but remains awake and alert and with a normal mind. Patients with
locked-in syndrome are those in whom a lesion, usually hemorrhage or an infarct, transects the
brain stem at a point below the reticular formation (therefore sparing consciousness) but above
the ventilatory nuclei of the medulla (therefore precluding death). Such patients are awake, with
eye opening and sleep-wake cycles, but the descending pathways through the brain stem
necessary for volitional vocalization or limb movement have been transected.
Brain death. This is an irreversible cessation of all brain function. Brain death may result from
any lasting or widespread injury to the brain.
Clinical presentation generally depends on cause of the some, where its easy to diagnose coms,
its always not easy to determine the cause, yet it’s a very most important aspect of management
History : Try to elicit important history that could lead to un consciousness
- Past medical history ( DM, HTN, EPILEPSY, ASTHMA, COPD,
- Trauma
- H/o fever
- H/o seizures
- Alcohol use and substance abuse
- Ambulatory medications
- Last meal
- Visual problems in the past (pituitary tumour )
- Headache
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Therefore carry out a general examination
This may give further clues to the diagnosis, for example:
• Jaundice: Malaria, hepatic encephalopathy, septicaemia
• Ketotic breath and dehydration: Diabetic ketoacidosis
• Laceration of the tongue and incontinence: Epileptic seizure
• Poor dental hygiene, ear discharge: Intracranial infection ? bacterial meningitis ,
• Lung consolidation: Meningitis, brain abscess
• Hepatosplenomegaly: Malaria, hepatic encephalopathy
• Hypertension: Hypertensive encephalopathy, stroke
• Obvious wound on the head, bleeding from ENT - Traumatic brain injury
Pupil assessment is often a critical portion of a comatose examination, as it can give
information as to the cause of the coma; for example
Pinpoint" pupils may indicate heroin or opiate overdose, organophosphate
poisoning, or pontine heamorrhage
One pupil is dilated and unreactive, while the other is normal (in this case the R
eye is dilated but the L eye is normal in size). This could mean a damage to the
oculomotor nerve (cranial nerve number 3, CN III) on the right side, or possibility
of vascular involvement say from stroke
Both pupils are dilated and unreactive to light. This could be due to overdose of
certain medications, hypothermia or severe anoxia (lack of oxygen).
Look for evidence of head injury
– Lacerations or bruising to the head or face
– Signs of a basal skull fracture
• Battle’s sign (bruising behind the ear)
• Periorbital ecchymosis (bruising around the eyes)
• CSF rhinorrhea or otorrhea (CSF leaking from the nose or ears)
• Haemotympanum (blood behind the eardrum)
Look for evidence of meningitis
• Fever
• Neck stiffness (meningism)
• Kernig’s sign :When the hip is flexed to 90°, the knee cannot be straightened due to
spasm of the hamstrings caused by inflammation around the lumbar spinal roots
Petechial rash
This is seen in meningococcal meningitis with septicaemia.
Ensure to score the patient on the coma scale
GCS score = Eye opening + Motor response + Verbal response
(1 to 4) (1 to 6) (1 to 5)
Minimum score = 3
Maximum score = 15
Investigation of the comatose patient
• Blood and Urine tests
– Malarial films
– Blood cultures
– Biochemistry and haematology
– Endocrine studies
– Drug screen
• Skull Xray
– May reveal a skull fracture
• Chest Xray
– May show pneumonia, PCP, bronchial carcinoma
Lumbar puncture
– This is useful in the diagnosis of meningitis and encephalitis, but is
contraindicated in the presence of focal neurological signs or papilloedema,
unless a CT scan is done first, as it may cause coning
Normal Bacterial meningitis Tuberculous Viral meningitis
meningitis
Appearance Clear Cloudy Fibrin web Clear
Cells <5 / mm3 <90-1000 / mm3 polymorphs 10-350 / mm3 50-1500 / mm3
mononuclear cells polymorphs mononuclear cells
Protein 0.2-0.4 g/L >1.5 g/L 1-5 g/l <1 g/L
2
Glucose /3 to ½ plasma glucose < 2/3 plasma < 2/3 plasma > 2/3 plasma
Organisms None Present in smear and culture Often absent in Not present in smear or o
smear but present in culture
prolonged culture
Management
- This will depend on the underlying cause
- Important principles are
- Look after the Airway Breathing and Circulation first
- Rapidly diagnose and treat the treatable causes, like malaria, meningitis, hypoglycaemia
and hypertension
- Monitor the patient closely for any deterioration in their GCS, or change in pupil
reaction.
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