MANAGEMENT SESSION ON APPROACH TO

COMA PATIENT
Presenter: Dr. Natinael Melese.

Moderators: Dr. Weldemichael Y. (Internist)

: Dr. Eyobe.(GP)
Outline
• Case presentation • Neurologic Examination
• Level of consciousness • Investigation
(arousal)&Definition of Coma • Management & follow up of
• Coma mimickers Coma
• Immediate life saving
management
• Causes of Coma(Differential
Diagnosis)
• History & Physical examinations
 Case Presentation

• AGE = 18 NAME = MX
• SEX = Male MRN =017631/15
• DATE = 06/6/2015

C/C = Loss of consciousness of 12 hr duration

This 18 years old male patient presented with acompliant of loss

of consciousness of 12 hr duration.also has hx of global type of headache
and vomiting of engested matter of 2 days duration.also has hx of HGIF of
same days duration. 5 days back has hx of trauma to his Lt temporal area
while faighting with assailant. then after he developed headache and
nausea.
• Otherwise = No hx of ABM
No hx of chills rigor
No hx of DM and HTN
No hx of SOB and cough
PE
GA = ASL
V/S = BP 114/65 PR 115 RR 23 SPO2 92 % Tm 38.4 0C
HEENT= Pink conjuctiva non icteric sclera
LGS = No LAP
RS = Coarse cracles heard on bilateral chest
CVS= S1 and S2 well heard no murmur , s3 gallop
ABM= No organomegaly, no sign of fluid collection
GUS= No CVAT, no SPT
IS = No pallor
MSK= No edema
NS= In Coma
GCS 6/15 E=1 V=1 M= 4
pupil: mid sized and reactive
Motor:
sensory:
meningial sign: Kernig sign +ve and neck regidity +ve

ASSESMENT: COMA seconrdry to pyogenic menigitis + ? cerebral

malaria PLUS Aspiration pnemonia.
INVESTIGATION
• RBS 121 mg/dl, 106 mg/dl
• CBC WBC 54.2 HGB 19.5 MG/DL
GRAN 80.2 % HCT 53.9%
LYM 5.2 % MCV 91.2 fl and PLT 202

OFT : AST 102 CRE 0.97

ALT 34 BUN 21
Head CT : Unremarcable
Managment
INO2
Ceftriaxone 2gm iv Bid
Vancomycine 1gm iv TID
Metronidazole 500 mg iv Tid
Intubated at ICU
Frequent suctioning Q2hr
NG tube feeding 300ml Q3hr
RBS QID
Artisunate 2.4mg/kg
DATE ASSESMENT TREATMENT ADDED SUBJECTIVE OBJECTIVE
PROGRESS
7/06/15 COMA secondry to pyogenic omeprazole 20 mg iv NO new compliant V/S BP 128/76 PR 104
mengitis +? cerebral Bid
malaria+ UFH 500 iu sc BID RR =23- 26
spiration pneumonia
SPO2 97% To 36.9

RS =coarse cracles on bilateral

chest
NS=GCS 4T Afternoon 7T
PUPILS =mid sized &
reactive
PLAN CBC,RBS QID

08/06/15 “ “same” Hold UFH NO new compliant V/S= BP 138/80 PR 98

thiamine 500mg iv
daily for 2 days then
200mg daily for 5 days RR 32
phenytoin 100 mg po
tid SPO2 98 T 37.4

NS= GCS= 7T
PLAN= HEAD CT
DATE ASSESMENT TREATMENT ADDED SUBJECTIVE OBJECTIVE
PRO....
10/06/15 “SAME” plus improving PUT on MF NO new compliant V/S BP=104/60
Hold Artisunate PR=70
Extubated RR=23
chest physiotheraphy T=37.2
Q2hr SPO2=94%
NS =GCS 8T/15

PLAN = Transfer to
E- ward
Discharge summery
• This is a 18 years old male patient admitted 9 days back with
adiagnosis of COMA secondry to PYOGENIC MENIGITIS plus ?cerebral
Malaria plus ASPIRATION PNEUMONIA AND rx with ceftazidime 1gm

iv Tid ,vamcomycine 1gm iv Tid and metronidazole 500 mg iv Tid for

fourteen days and Artisunate 2.4 mg/kg iv five dose
Was intubated at icu for two days before transferred to ward
Currently discharged with stable vital signs.
 Definition
• Coma is a state of extended unconsciousness in which the patient is unarousable and
shows little or no spontaneous movement and little or no alerting response to painful or
noxious stimuli.

Anatomy & Physiology

• For a person to maintain consciousness two important neurologic components must
function impeccably. This are;

.Cerebral cortex

.Reticular activating system(RAS)

LEVEL OF TECHNIQUES PATIENT RESPONSE
CONSCIOUSNESS
(AROUSAL)

ALERTNESS Speak a normal tone of Opens the eyes, looks at you, and responds fully and
voice appropriately to stimuli
LETHARGY Speak in a loud voice Appears drowsy but opens the eyes and looks at you, responds
to questions, and then falls asleep
OBTUNDATION Shake gently as if Opens the eyes and looks at you, but responds
awakening a sleeper slowly and is somewhat confused
Alertness and interest in the environment are decreased

STUPOR Apply a painful stimulus Verbal responses are slow or even absent
The patient lapses into an unresponsive state when the
stimulus ceases
There is minimal awareness of self or the environment
COMA Apply repeated painful Remains unarousable with eyes closed
stimuli There is no evident response to inner need or external stimuli
Coma mimickers
a) The locked in state
• Is a type of pseudocoma & a patient is awake,fully alert
• But no means of producing a speech & no limb movement
• There is only voluntary vertical eye movement
• Pupils are normally reactive
• Patients have intact cognitive function
• Only they lack the motor response
• Occur due to pontine hemorrhage,basilar artery thrombosis
 b) Vegetative state
• An aware appearing but not responding
• Eye lid may open periodically which give appearance of wakefulness
• All vital sign like BP,PR,RR are normal because part of brain controlling these are
normal
• They can breath, suck,chew,cough,swallow.
• They have no awerness of them self and their environment

• If last greater than 1 month we call PVS

• Occur when cerebrum(part of brain that control thought and behavior) damaged
severely
• But the hypothalamus and brain stem are normal
 c)Akinetic mutism
• Patient is partially or fully awake
• Patient is able to form impression and think
• But remain immobile&mute
• Occur due to damage to the medial thalamic nucli or the
Frontal lobe
• It results from damage in the region of the medial thalamic nuclei or
frontal lobe
 d)Abulia
• It is milder form of akinetic mutism
• Apathy being less extreme than abulia
• Refers to lack of will or initiative
• It can be seen as disorder of diminished motivation
• It results from damage to the medial frontal lobes & their connection
Approach to the Patient
 Generally when we approach comatose pt. we have to follow :
• Immediate life saving management
• History and General examination
• Neurologic examination
• A complete medical evaluation
• Basic lab tests
Immediate life saving
management
 Acute respiratory and cardiovascular problems should be attended
prior to neurologic assessment.( ABCDE way of life )
• A-Secure airway
• B-Breathing. ( Estabilish adequate ventilation )
• C-Circulation ( Check pulse )
• D-Disability ( quick ass’t of neurologic exam. )
• E-Exposure
 Then proceed to administration of coma Cocktail.
General Measures

The initial emergency management of coma can be remembered by

the mnemonic ABCD,
• for
• Airway,
• Breathing,
• Circulation, and
• Drugs
• -dextrose, thiamine, and naloxone or flumazenil), respectively
 A: Air way maintenance and
cervical spine stabilization
• Check the patency of the air way
• Remove any thing that block the air way
• The patient can be positioned on one side with the neck partly
extended, dentures removed if there is
• Tongue is the single most common cause of air way obstruction in
unconscious patient
• protection of C spine by immobilization
Cont’d
endotracheal Intubation
• If any of the following criteria:
• GCS < 8
• Frequent vomiting or poor gag or cough reflex
• Any significant respiratory failure
• Presence of hypoxemia (oxygen saturation of <90 percent)
B. Breathing and ventilation
If the patient has any trouble with breathing ventilate with one of the
following technique:
• Mouth to mouth breathing
• Mouth to nose breathing
• Intra nasal oxygen with nasal catheter
• Oxygen with face mask
• Give 100% oxygen at high flow
C. Circulation
• Replace fluid
• Vasopressor like norepinephrine or dopamine if low systolic pressure
in spite of fluid
• Do not use hypotonic solutions to treat shock, particularly patients
with coma or possible cerebral edema
• Do not restrict fluid in comatose patient with inadequate intravascular
volume
• Identify life threatening hemorrhage and control it
D. Drugs (Coma Cocktails)
• 25 g of dextrose (as 50 mL of a 50 %t dextrose solution) while waiting
for the blood tests, if the cause of coma is unknown

• Thiamine, 100 mg, in any patient who may be malnourished or

alcohol consumption

• naloxone (0.4 to 2.0 mg IV)

• Flumazenil(0.2mg IV)
 Supratentorial

Symmetrical
infratentorial

Structural Supratentorial
Asymmetrical
infratentorial

Coma Toxic

Metabolic
Non-structural Symmetrical Infectious

Psychiatric
Ddx
History taking for comatose
patient
 The patient with impaired consciousness probably cannot contribute
a history but source of history can be :
• Witnesses (police man), friends or family members, and
emergency medical technicians.
• Medical Alert bracelet or necklace and/or a card in the wallet may
contain a list of illnesses and medications.
• Ambulance technicians on the scene,
• in person or by telephone
• An old hospital chart.
Cont…
 Time course of the loss of consciousness?
• Abrupt
• Subarachnoid hemorrhage, seizure
• Gradual
• Brain tumor
• Fluctuating
• Recurring seizures
• Subdural hematoma
• Metabolic encephalopathy
History…
 The antecedent symptoms (confusion, weakness,
headache, fever, seizures, dizziness, double vision, or vomiting);
• Focal symptoms preceding loss of consciousness suggest structural
lesion;
• A fever suggests infection;
• An increasing headache suggests an expanding intracranial lesion,
infection, or venous sinus thrombosis
• Recent falls raise the possibility of a subdural hematoma;
• Recent confusion or delirium might indicate a metabolic or toxic
cause.
History…
 Previous similar episode
 TIA, Postictal coma
 The use of medications, illicit drugs, or alcohol; and
 Chronic liver, kidney, lung, heart, or other medical disease
 Trauma, Nonaccidental trauma( child abuse )
Physical examination
 General appearance
 Vital sign
• Blood pressure
• Pulse rate
• Respiratory rate
• Temperature
 HEENT
• Scalp laceration, battle’s sign,raccoon eye
• Fundoscopic examination,rhinorrhea, otorrhea&Tongue bite marks
Systemic examination
• LGS: enlarged LNs , Goiter
• Chest: pulmonary edema
• CVS: Arrhythmias, new murmurs
• Abdomen: abnormal bowel sounds, organomegaly, masses, ascites,
blood in the rectum
• GUS: urinary incontinence
• ING:cyanosis ,pallor,petichial purpuric rash,ecchymosis
• MSS: subtle twitching of extremity
• Other system signs may give clues to the underlying pathology
causing coma
Neurologic Examination
Assess:
• Level of consciousness:
1.Glasgow coma scale
2.The Four scale
• Brainstem reflexes
1.pupillary&eye movements
2.corneal reflexes
3.respiratory patterns
• Motor responses
1.posturing
2. muscle tone & power
3. tendon reflexes&plantar responses
 1. The Glasgow Coma Scale
EYE OPENING BEST VERBAL RESPONSE BEST MOTOR RESPONSE
Spontaneous 4 Oriented 5 Obeys commands 6
Response to verbal 3 Confused 4 Localizing response to pain 5
command

Response to pain 2 Inappropriate words 3 Withdrawal response to pain 4

No eye opening 1 Incomprehensible sounds 2 Flexion to pain 3

No verbal response 1 Extension to pain 2

No motor response 1
 2. The Four Score
Eye response Brainstem reflexes
4 = eyelids open or opened, tracking, or blinking to command 4 = pupil and corneal reflexes present
3 = eyelids open but not tracking 3 = one pupil wide and fixed
2 = eyelids closed but open to loud voice 2 = pupil or corneal reflexes absent
1 = eyelids closed but open to pain 1 = pupil and corneal reflexes absent
0 = eyelids remain closed with pain 0 = absent pupil, corneal, and cough reflex
Motor response Respiration
4 = thumbs-up, fist, or peace sign 4 = not intubated, regular breathing pattern
3 = localizing to pain 3 = not intubated, Cheyne-Stokes breathing pattern
2 = flexion response to pain 2 = not intubated, irregular breathing
1 = extension response to pain 1 = breathes above ventilator rate
0 = no response to pain or generalized myoclonus status 0 = breathes at ventilator rate or apnea
Brainstem Reflexes
Ocular movements
• Position of eyes at rest
• Toward hemispher lesion
• Away from brain stem lesion
• Turn down and inward with
• Thalamic
• Upper medbrain lesion.
• Ocular bobbing-
• Bilateral pontine
• Ocular dipping
• Anoxic cortical damage
Cont...
• Reflex ocular movements
Oculocephalic reflex (“doll's eye phenomenon\reflux”)
• Neck stability
Caloric (thermal) testing/oculovestibular testing
• Intact tympanic membrane
Oculocephalic reflex
Caloric testing
Corneal reflex
• Test the fifth nerve sensory and seventh nerve motor
• Cotton on cornea and look for a blink or watch the lower eyelashes
move toward the midline
• Good test for mid and low pontine dysfunction
• Bilaterally absent corneal reflexes can be seen with
• Extensive structural lesions within the pons.
Respiratory patterns in patients with altered level of
consciousness
PATTERN DESCRIPTION LOCALIZATION
CHEYNE-STOKES RESPIRATION Slowly oscillates b/n Bilateral hemispheric dysfunction
hyperventilation & apnea
KUSSMAUL BREATHING Deep, regular respiration Diffused cerebral cortex
metabolic acidosis
CENTRAL NEUROGENIC Rapid breathing, from 40 - 70 Low midbrain ventral to aqueduct
HYPERVENTILATION breaths per minute of Sylvius & upper pons ventral to
4th ventricle
APNEUSTIC BREATHING Prolonged inspiratory gasp with a Dorsolateral lower half of the
pause at full inspiration pons
CLUSTER BREATHING Periodic respirations, irregular in High medullary damage
frequency & amplitude, with
variable pauses b/n clusters of
breaths.

ATAXIC BREATHING Irregular in rate and rhythm Dorsomedial part of the medulla

APNEA No respiration Medulla down to C4, peripheral

nerve, NMJ, muscle
Motor Examination
• Assess
• Muscle tone
• Spontaneous and elicited movements and
• Reflexes
• Asymmetries indicate a hemiplegia of the non-moving side, implying a
lesion affecting the opposite cerebral hemisphere or upper brainstem.
Cont...
• Motor function is assessed by Motor response to the application of a
noxious stimulus. Pressure applied to the
• Supraorbital ridge
• The nail bed or
• The sternum are easily elicited noxious stimuli associated with a
minimum of tissue trauma.
• Three patterns of responses may be observed:
• Appropriate
• Inappropriate, and
• No response
 Cont’d
Assess deep tendon reflux
Muscle tone-check spasticity VS flaccidity
Do plantar reflux
Other neurologic examination
.Gag reflex
. Meningeal sign
 Investigations
• Liver function studies
• Thyroid function studies
 Laboratory studies
• Plasma cortisol level
• Blood
• Drug and toxin screen
glucose level
• Serum osmolality
• Complete  Imaging like:-
blood count
• Chest x ray
• Electrolytes:
• BUN ,Creatini • Cranial CT or MRI
ne
• PT, aPTT
Management of Patients with Coma
• Can be divided into
1) General Measures

2) Specific Measures
• aimed at establishing the precise diagnosis and give the
definitive treatment
Cont’d
The immediate goal:
• prevention of further nervous system damage

• Maintenance of respiratory status

• Normalization of cardiovascular function

• Correction of acid-base, fluid and electrolyte abnormalities

• Essential elements of clinical evidence

1. Widespread cortical destruction

Deep coma and unresponsiveness to all forms of stimulation

2. Global brainstem damage

Absent pupillary light reaction& the loss of oculovestibular and corneal

reflexes

3. Destruction of the medulla

Complete and irreversible apnea
Coma Subsequent Management(Coma Care)
• Prevent bedsore:
• change position every two hour
• avoid wet clothes
• Protect eyes by keeping closed/lubricants
• Passive limb exercises to prevent contractures
• Aseptic/intermittent catheterization for bladder care and urine output
monitoring
• Insert NG tube to aspirate stomach contents
• Calf exe/stocking/heparin to avoid DVT
• Ranitidine to prevent stress ulcer
Prognosis
• Coma is a transitional state that rarely lasts more than several weeks,
except in cases of ongoing sedative therapies or protracted sepsis.
• Patients either recover or evolve into brain death or a persistent
vegetative or minimally conscious state.
• Prognosis depends on the underlying etiology, as well as the severity
of the insult and other premorbid factors.
 Pitfalls

• No documentation if immediate life saving was given at emergency

• Physical examination finding not documented well
• SPO2 record whether it is off or on oxygen not documented
References

• HARRISON’S PRINCIPLES OF INTERNAL MEDICINE, TWENTIETH

EDITION
• UPTODATE 2018
• CURRENT MEDICAL DIAGNOSIS AND TREATMENT (EMERGENCY
MEDICINE) SEVENTH EDITION
• STG,2020
THANK YOU!!