COMA
DIAH MUSTIKA HW,SpS,KIC
INTENSIVE CARE UNIT of EMERGENCY DEPARTMENT
NAVAL HOSPITAL dr RAMELAN, SURABAYA
DEFINITIONS
Coma
• State of unresponsiveness to external or internal stimuli
in which a patient lies w/ eyes closed unaware of the
environment
Consciousness
• State of awareness of both the self and the environment
• ARAS : rostral pons,
midbrain, thalamus,
Arousal hypothalamus
• Wakefullness or alertness
• Cerebral cortex and
connection to subcortical
Content white matter
• Attention, memory,motivation
and executive function
Pathophysiology:
• Consciousness depends on proper function of
both cerebral hemispheres and the reticular
activating system (RAS)
• Normal function requires
– Adequate substrate (primarily glucose)
– Cofactors
– Waste removal
– Adequate blood flow needed for delivery/removal
Levels of Arousal:
Alert : fully consciousAAlert: Fully conscious
Lethargic: appear somnolent, but may be able to maintain
arousal spontaneously or with repeated light stimulation
Obtunded: requires touch or voice to maintain arousal
Stuporous: unresponsiveness from which the individual can
be aroused only by vigorous and repeated stimulus
Comatose: state of unarousable unresponsiveness in which
individual lies with eyes closed, lacking awareness of self
and environment
Coma
• State of reduced alertness and
responsiveness from which you cannot be
aroused
• Glasgow Coma Scale
– Motor, verbal, eye opening
Motor
Response Example Score
Commands Follows simple commands 6
Localizes Pulls examiner's hand away
Pain when pinched 5
Withdraws Pulls a part of body away when
from Pain pinched 4
Abnormal Flexes body inappropriately to
Flexion pain 3
Body becomes rigid in an
Abnormal extended position when
Extension examiner pinches him 2
No Response Has no motor response to pinch 1
Eye-Opening .
Spontaneous Opens eyes on own 4
Opens eyes when asked to
To Voice in a loud voice 3
To Pain Opens eyes when pinched 2
No Response Does not open eyes 1
Verbal Response
(Talking) .
Carries on a conversation
correctly and tells examiner
where he is, who he is, and
Orientated the month and year 5
Confused Seems confused or
Conversation disoriented 4
Talks so examiner can
understand him but makes
Inappropriate Words no sense 3
Makes sounds that
Sounds examiner cannot understand 2
No Response Makes no noise 1
Evaluation:
• History
• Physical Exam
• Laboratory and Imaging Studies
Evaluation—History:
• Rapid initial history:
– Recent history prior to mental status changes
– Past medical history (seizures)
– Family history (specifically seizures/neurologic disorders)
– Trauma ?
– Febrile ? / Other signs or symptoms of infection
– Diet
– Exposure to drugs/toxins
• Follow-up with more complete history:
Evaluation—Physical Exam:
• Systemic
– Vital Signs
– Signs of trauma
– Signs of infection
– Signs of bleeding
– Signs of other systemic illnesses
Evaluation—Physical Exam:
• Rapid Neurologic Exam:
– Pupils
– Respiratory pattern
– Stimuli needed to elicit response
– Character of the response
Neurologic Exam—Pupils:
Respiratory patterns:
Location Pattern
Cheyne-Stokes
Hemispheric
Central
Midbrain Hyperventilation
Mid/Lower Pons Apneustic
Low Pons/Upper Cluster
Medulla breathing/Gasping
Medulla Agonal breathing
Posturing:
Decorticate Decerebrate
lesion above lesion below
midbrain midbrain
Common etiologies of coma
Structural Lesions
Supratentorial
Generalized/bilateral
Infectious/positinfectious
Encephalitis
Acute disseminated encephalomyelitis
Vascular
Anoxic – ischmenic encephalopathy
Multiple cortical infarctions
Bilateral thalamic infarctions
Traumatic
Diffuse axonal injury
Penetrating brain injury
Multiple contusions
Neoplastic
Glimatosis
Leukoencephalopathy
Multiple brain metastases
Lymphoma
Focal (with mass effect)
Intraparenchymal hematoma
Large stroke with edema
Abscess
Tumor
Infratentorial
Brain stem
Pontine hemorrhage
Basilar artery thrombis
Central pontine myelinolysis
Cerebellum
Infraction with edema
Hematoma
Abscess
Tumor
Metabolic derangements
Hypoglycemia
Hyperglycemia (nonketotic hyperosmolar)
Hyponatremia
Hypercalcemia
Panhypopituitarism
Hyperbilirubinemia
Acute uremia
Diffuse Physiologic Brain Dysfunction
Status epilepticus
Poisoning
Drug overdose
Gas inhalation
Hypotthermia
Basiliar migraine
Malignant neuroleptic syndrome
Hypoxia
Psychogenic Unresponsiveness
Catatonia
Conversion disorder
Malingering
Adapted from Ziai WC. Coma and altered consciousness. In Bhardwaj A, Mirski
MS, Ulatowski JA (eds), Current Clinical Neurology : Handbook of Neurocritical
Care. Totowa, NJ : Humana Press, 2004, pp 1 – 18
EMERGENT MANAGEMENT
Stabilization
• Assess Airway
• Is the airway clear?
– If not, use suction to clear
• Consider using airway adjuncts to maintain an open
airway
– Oral airway
– Nasal airway
– Advanced providers: Consider the need for
intubation
Stabilization
• Assess Breathing
– Determine if adequate or inadequate
by
• Rate
– Too fast, too slow, or normal
• Adult- 8-24
• Child- 15-30
• Infant- 25-50
• Tidal volume
– Amount of air moving in and out
• Normal depth, shallow, or deep
Stabilization
• Breathing
• Adequate rate AND tidal volume:
• Apply Oxygen 15 L NRB
• Inadequate rate OR tidal volume
• Oxygen 15 L Bag Valve Mask
Stabilization
• Assess Circulation
– Assess pulse
• Rate, quality, regularity
– Assess skins
• Color, temperature, moisture
– Check for and control major
bleeding
• Determine patient priority
Stabilization:
• Airway
– Assess for patency
– Assess for ability to protect
• Breathing
– Assess ventilation
– Assess breathing pattern
• Circulation
– Assess measures of cardiac output
• Hyper or hypothermia should reversed
appropriately to normothermia
Stabilization:
• D = “Da brain”
• Decision point
Concern for No concern for
increased ICP increased ICP
Stabilization:
• Increased ICP Must act immediately
• No increased ICP Time to consider your workup
Assessment and Management
• SAMPLE History
– Signs and symptoms
• Gradual or sudden onset?
• Did they get progressively worse?
– Allergies
– Medications
• prescription, nonprescription and illegal
• last doses
– Last oral intake
• Any alcohol?
– Events leading up to
• Any seizure activity? Any trauma in last two
weeks? Any complaints of headache?
• Was patient acting normal prior to events?
Assessment and Management
• Physical Exam
– Head- any evidence of trauma
– Pupils
• Unequal or fixed- increased intracranial
pressure (head injury or stroke)
• Pinpoint- narcotics
• Sluggish- hypoxia
– Mouth and oral mucosa- check for cyanosis
– Chest- trauma, equal rise and fall of chest,
lung sounds
– Abdomen- trauma, check for tenderness with
palpation
– Extremities- pulse, movement, and sensation;
edema in lower extremities
Assessment and Management
• If assessment findings indicate
potential stroke, do a FAST
Assessment
– Face
• Smile, is one side drooping?
– Arm
• Raise arms, does one side drift down?
– Speech
• Repeat a phrase, are your words slurred?
– Time
• Quick treatment with any of the above
Assessment and Management
• If low blood sugar is present:
– Administer oral glucose if patient is alert and
able to swallow (Basic providers)
– Dextrose 50% IVP or Glucagon IM (Advanced
providers)
• If narcotic overdose is suspected and
airway compromise and/or inadequate
respiratory effort is present:
• Narcan IV or IM (Advanced providers)
Thanks for your attention
