C H A P T E R

Practical Approach to a Person

21 Who is Unconscious
Nagarajan Venkataraman

ABSTRACT unconsciousness, caused by varied etiology, for example

Identification and management of acute coma or loss of severe stroke syndromes, brain tumor going in for
consciousness is a clinical challenge. Most of the time, conning, head injury, encephalitis, other CNS infections,
the patients are brought by unknown people, or with alcohol or toxic drug intoxications, so on so forth. The
relatives with little details. Assessing the management, conscious level is maintained by the ascending reticular
depends on the etiology, which has wide varieties. activating system in the brain stem.1 And it is maintained
Hence it is mandatory that etiology of the coma, has to be by volleys of projections to the cortical system, by it’s lots
determined, before managing the case. Many causes right of inputs from various sensory, motor projections. The
from head injury, cerebro vascular accidents, infections of cortical alertness is maintained by such projections from
CNS, and metabolic causes result in coma. Wide tracking ARAS to the cortex. Its functions are compromised either
of causes, by repeated patient questioning to the relatives, mechanically, or by toxins and toxic metabolites.
at the same time, carrying out the emergency measures to
recover the patient’s health is imperative. The concept of
SYMPTOMS
“Time is Brain” has to be borne in mind, and a work up LOC or Coma, has fairly definite, constant symptoms
quick, investigations for the cause of coma, will make a 1. The eyes are closed.
physician’s effort highly successful one. 2. Non responding pupil, some times asymmetric or
pin point and nonresponsive as in subarachnoid
INTRODUCTION hemorrhage.
A patient brought to your office, in an unconscious state,
is a challenge to the Physician, as there are numerous 3. Depressed brain stem reflexes, as evidenced by
causes for the loss of consciousness, right from common depressed ocular movements.
hypoglycemia to a dangerous situation like subarachnoid 4. No movement in the limbs, and occasionally some
hemorrhage. The relatives will be highly apprehended, reflex movements.
to know the fact regarding recovery, prognosis, even
doubts about our capability, approach, and efficiency. 5. Ataxic breathing, cold clammy skin, and in
Mostly some will be urging to take the patient to a metabolic coma, special odors like uremic odor or
corporate hospital. We have to face lots of problem, apart fruit odor of DKA.
from looking into the patient’s welfare, the other issues 6. Seizures may manifest if the cause is cerebrally
also. Mostly, they want an answer immediately, about oriented, like inflammation or ICH.
the survival and prognosis of the patient. A calm, quiet,
confident, and efficient approach will win all the issues. Bed side approach to an unconscious patient
The following points are necessarily to be examined. First
Definition
LOC or coma, is a clinical condition of prolonged

Table 1: Evaluation of coma from pseudocoma

Method of examination Functional (Psuedo coma) Organic
1 Plantar response Withdrawl or flexor Extensor
2 Pupil Normal and reactive Abnormal, non reactive
3 Tone of muscles and limbs Variable Either flaccid or spastic consistently
4 Bladder status Never incontinent Mostly incontinent
5. Blood pressure Mostly normal Variable
6 Respiration Hyperventilation Ataxic or shallow
7 Neck stiffness, classical variable Consistent
8 Forcible eye opening by the examiner Resistance observed No Resistance
9 Reflex eye movements Invariably present May or may not be present depending
on the brain stem integrity
 108 will be given. We have to analyze the correct
Table 2: Common Etiological issues in COMA
pathway, of identifying the cause, is necessary
• Traumatic brain injuries.  towards the management of the patient. To achieve
Trauma due to road traffic, fall, violence, blasts that, one should examine the patient in depth,
injuries. to a possible extent, regarding the etiological
• Stroke. Subarachoid Hemorrhage, intracerebral discoveries, and apply the same towards eliciting
massive bleed, or major vessel occlusion as in the history. Based on the history elicited, further
carotid massive occlusion, along with compromised examination is mandatory. It is highly pertinent to
brain stem circulation or due or massive brain remember, that what ever history is given should
oedema and coning. correlate with our clinical findings, otherwise we
• Diabetes Mellitus. may be dragged to different etiology, missing the
Hypoglycemia (acute onset coma) and proper diagnosis.
hyperglycemia. (subacute onset coma)
NEUROLOGY

2. In comatose patient’s examination, there will be no

• Uremia – Sub acute onset of loss of consciousness, resistance for examination but we should not take
with obvious history. it to our advantage. A patient with head injury,
• Lack of oxygen.  and coma, may have dislocated cervical injury, and
Drowning of post CPR. examination for neck stiffness should be extremely
• Infections.  careful, as there may not be any resistance. Partial
Encephalitis and meningitis. Toxemia, dislocation of spinal discs, will become complete
Septicemia. on extreme cervical movements, on examination.
• Seizures. Status epilepticus, post ictal coma, 3. Look for more injuries like abdominal injuries,
• Toxins.  spleen, liver and any other hollow viscous rupture,
Carbon monoxide, organophosphorous compounds even before attending to the patient with head
or lead, injury and coma, as subsequent examination
will be targeted only towards head injury, and
• Tumors of the brain,
death of patient may be due to other concomitant
Sudden bleeding inside the tumor causing acute
causes. It is always better to examine in a routine
swelling,
way from top to toe. Look for any cause that
massive brain edema as seen in high malignant
tumors, may be responsible for the coma. This procedure
edema and coning of the brain stem. is essential to identify the injuries which may
become life or limb threatening. Any negligence to
• Alcohol – identify the other lesions, may be left untreated till
Acute alcoholic intoxication results in coma. the patient recovers from the coma. The common
• Drugs - Marjuvana, opioids issues are hip dislocations, spinal fractures, and
fractures of metacarpals. It is essential that every
thing to rule out is the functional causes of the so called joint should be put into full range of movements, to
LOC (Table 1). assess the integrity of the long bones. Where ever,
Approach To The Etiology (Table 2). One has to do Police suspicion results X ray should be done in that area.
Man’s Job, in detecting the etiology. Injuries in the back, and medical conditions like
pneumothorax, should not be missed. Palpation of
1. The following questions may give pathway to the peripheral pulse is mandatory.
examination in a case of coma.
4. History of injury immediately or in recent past,
• Had the LOC started suddenly or gradually? however trivial it may be, is very important.
• Whether it was accompanied with problems in A subdural may be “quiet” for some time, and
the vision, such as loss of vision, diplopia, vertigo, suddenly it may enlarge and cone the brain stem.
fainting spells, or numbness of the limbs etc ? Many of the patients who had mild subdural due
to trivial head injury, may land in enlargement
• Is the patient a known case of diabetes, or patient of the subdural, if they were on medications with
on dialysis, seizures or old stroke ? antiplatelet drugs for some other ailment. This
• Had the patient severe headache prior to the LOC ? may cause coning, which will become a practical
problem.
• Any mental changes observed, prior to LOC, like
confusion, frequent falls etc ? 5. Non surgical causes of loss of consciousness are
many,which are tabulated (Table 1). Look for
• Did the affected person use any medications with
evidence for such etiology in case, if you could
or without prescription ?
exclude surgical causes. But never compromise one
A very detailed history from the accompanying for other. For example, simple alcoholic coma, may
person, if available, regarding the situation of the be associated with subdural, and a careful watch
patient, is mandatory. Invariably, various histories for both, is mandatory. Vice versa, a case of head
 109
Table 3: Elements of the scale
Glasgow Coma Scale
1 2 3 4 5 6
Eye Does not open Opens eyes in Opens eyes in Opens eyes N/A N/A
eyes response to response to spontaneously
painful stimuli voice
Verbal Makes no Incomprehensible Utters Confused, Oriented, N/A
sounds sounds inappropriate disoriented converses
words normally
Motor Makes no Extension to Abnormal Flexion / Localizes Obeys
movements painful stimuli flexion to Withdrawal to painful stimuli commands

CHAPTER 21
(decerebrate painful stimuli painful stimuli
response) (decorticate
response)
Note that a motor response in any limb is acceptable.2 The scale is composed of three tests :eye, verbal and motor responses. The
three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while
the highest is 15 (fully awake person). Interpretation of Glasgow Coma Scale; Individual elements as well as the sum of the score
are important. Hence, the score is expressed in the form “GCS 9 = E2 V4 M3 at 07:35 minutes; Generally, brain injury is classified
as: Severe, with GCS < 8–9; Moderate, GCS 8 or 9–12 (controversial)4; Minor, GCS ≥ 13. Ref:  “The Glasgow Coma Scale: clinical
application in Emergency Departments”. Emergency Nurse. 14 (8): 30–5. 2006. doi:10.7748/en2006.12.14.8.30.c4221.

injury may be accompanied with metabolic or 5. Pressing the nasal ridge at the root in between the
alcoholic coma. eyes, and look for wincing.
6. One of the common causes of LOC is cerebro 6. Eliciting bone pain, by pressursing the shin of tibia
vascular accident. The coma results mostly in and the response of the patient.
massive intracranial bleed, due to hypertension,
All the above methods may give a fair response to the
aneurysm rupture, leading to acute subarachnoid
examiner, regarding the level of loss of consciousness,
hemorrhage. Acute intracerebral bleed, if massive,
which is very much essential to fix the prognosis.
or massive carotid infarcts, do result in LOC.
OBJECTIVE CLINICAL SENSORY RESPONSES
EVALUATION OF CMLOTOSE PATIENT 1. Oculo-cephalic movement reflex. This tests certifies
Assessment of level of consciousness is assessed by
the brain stem integrity. If present give a good
Glasgow Coma Scale, especially for comatose patients
prognosis, compared to no response.
with head injury. GCS can be used for other causes of
coma also. 2. Assure that there is no cervical bone injury, when
this examination is performed.
GLASGOW COMA SCALE (TABLE 3)2,3
3. Pupillary response, to light, is a mandatory
1. A practical hint to evaluate the prognosis, and
examination. A dilated non responding pupil is a
severity of the loss of consciousness. Predominantly
poor prognostic sign.
applied for head injury and CNS causes, and
usually not applied for metabolic causes. But for 4. Cilio spinal reflex can be observed if the papillary
practical purposes one can apply. response is normal.
2. Bed side approach. 5. Syringing the ear with sterile water, and trying to
elicit nystagmus, assessing the integrity of brain
Assessing the sensory status and response:
stem, connections with the higher brain centers.
1. Level of consciousness, is assessed by the sensory
6. Plantar response, is highly dubious, and depends
stimuli applied to the patient. By calling the patient
on careful observations of the response, and method
by his name, either by the examiner or by a close
of elicitation. Bing’s response is more reliable than
relative of the patient, and seeing the response.
Babinski’s. (Bing sign - sharp pressure pain over
2. Pinching, the skin of the limbs, clenching the the dorsum of foot )
Achilles tendon for deep pressure pain response.
7. Tone of the muscle, is an index of severity or
3. According to some Senior authors, squeezing the organicity of the LOC. A variable tone is a sign
nipple is another method, which is not practiced of non organic LOC, where as, a constant tone,
now on ethical issues. as increased or decreased, could be marked as an
4. Assessing the corneal reflex, carefully with a sterile organic cause of LOC. A continuous flaccid tone is
cotton wisp and looking for the response. associated with poor prognosis.
 110 supplementation of oxygen is mandatory, by all
Table 4: Essential Investigations
means. It is preferable, over a period of 15 mts, if
• Blood sugar, blood urea estimation there are signs of compromised ventilation and
• Basal blood tests, like ESR, CBC, Hb oxygenation, detected by PO2 less than 70%, one
• Parasites in the blood, (malaria) should immediately switch over to the ventilator
drive. It is preferable to have 100% oxygen, to obtain
• CT Scan/ Followed by MRI saturation of 98% in the blood. This procedure
• Electro encephalogram. is highly important to save the neurons, and the
• Electrolytes/anion gap, pH determination remaining dying neurons.
• Renal function tests, urea, creatinine, GFR 3. In most of the patients who are comatose, the
• X-rays, urine basic tests retina runs to ischemia, and also if it is associated
with acute hypotension, and low O2 saturation.
• Acetylsalicylic acid/acetaminophen blood level
NEUROLOGY

O2 supplementation becomes more mandatory to

• Ethanol/osmolality prevent retinal dysfunction and death of neuronal
• Arterial blood gas/carbon monoxide levels layer. It is pertinent to observe that hypercapnea is
far less likely to render irreparable brain damage
• Lumbar puncture if necessary, and to be avoided
than hypoxia. More so the retinal damage is more
as much as possible
with hypercapnea, especially in CO2 poisoning,
8. Persistent tachy, bradycardia or rather arrhythmias severe macular damage is a usual sequelle.
is a sign of organic coma, with poor outcome. 4. Apart from this, infective causes also route to LOC.
Meningitis, especially pyogenic meningitis, should
INVESTIGATIONS (TABLE 4)
be treated with appropriate antibiotic.
Investigations have to be performed in a war foot
method. Any delay in the investigations will cause more One of the rare cause of LOC, of nutritional origin
devastating results in the recovery. Mind “Time is Brain”. is thiamine deficiency, may be associated with
situations where the alcoholism is highly prevalent.
THERAPY In alcoholic coma, even though the LOC is due to
The algorithm for management of coma is given in Figure toxic causes, an associated thiamine deficiency is
1. The first and foremost advise to the management invariable associate. Administration of the thiamine
of comatose patient, is application of 50% dextrose is mandatory in such situation.6
intravenous infusion as hypoglycemia is one of the most
common cause of coma, and the patient’s response is 5. Cerebral malaria should be treated with anti
dramatic.4 parastiticdal drugs, if MP is identified in the
peripheral smear. CSF, may be positive for MP, in
1. In patients with prolonged hypoglycemia, for more rare cases apart from the positive peripheral smear.
than an hour, or in patients with associated motor
seizures, recovery response may be delayed. Management of cerebral Malaria
Management is multifocal, right from all parameters
• It is observed, that patients with ischemic stroke,
of management of coma, cardiac monitoring etc,
if IV infusion of 50% dextrose may enhance the
appropriate drugs are as follows. The drug of
anaerobic glycolysis in infarcted area, to induce
choice is quinine and artesunate.
production of free radicals’, which are harmful to
the dying neurons. But it is also observed that most Artesunate has a limited shelf life. The dose is
of the ischemic stroke, do not cause comatose state, 2.4 mg kg−1  given intravenously, followed by the
and coma is uncommon in ischemic stroke, unless same dose at 12 and 24 h, then once daily until the
it is gross, hemispherical with progressive edema. patient is able to take artesunate (2 mg/kg per day)
Hence application of the dextrose need no worry.5 by mouth to complete 7 days, then Doxycycline
It is pertinent to observe, that rapid chemstrips 200 mg or Clindamycin daily by mouth for 7 days
may fail to endorse the clinical hypoglycemia in the There are many complications of artesunate, which
presence of numerical normoglycemia.5 By giving has to be balanced between the recovery and side
dextrose to an already hyperglycemic patient is effects of the drug
dangerous in a subtle way, than withholding it 6. Metabolic causes like diabetes mellitus with acute
from a hypoglycemic patient. hypoglycemia, requires immediate infusion of 50%
If one is afraid a trial dose of 50 ml of 50% dextrose glucose, 100 ml followed by 5% dextrose saline.
may be infused for elective result, and recovery Appropriate correction of acidosis in hyper osmolar
from coma.6 ketotic coma, with Ringer solution is mandatory.
2. Prevention of hypercapnea: Neuronal death 7. In renal failure, care should be taken to reduce
is rapid in the presence of hypercapnea. A the BUN, and patient should be dialyzed,
comatose patient has mostly has a compromised appropriately, with the correction of renal acidosis,
ventilator drive, which is deleterious. Immediate electrolyte abnormalities.
 MANAGEMENT OF COMA - An ALGORITHM

COMA-LOC CONCLUSION 111

Clinical Events
COMA or LOC, is a condition met with by every
practioner and consultant, which is a challenge to decide,
Organic Functional
treat, and to give a good recovery. Early and swift actions
of the consultant, practioner, and good co operation
Therapy Assessment
of the relatives, accompanying persons, to accept the
management, give funds for the tests, is a mandatory
Etiologically Managed Investigations
Assessment of issue. Since “Time is Brain”, an earliest intervention will
severity towards
Specific
Non-specific & Final clarified Regime with progress save the patient’s brain and life, to a great extent.
supportive ref. to Etiology

Fine tuning in the therapy REFERENCES

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Final Outcome
“Activation by attention of the human reticular formation

CHAPTER 21
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