APPROACH TO COMA

Dr Abdullah Ansari
Definition of Coma
Coma is a state of complete behavioral
unresponsiveness to external stimulation
Anatomy of consciousness

 Ascending reticular activating system (ARAS)

 Activating systems of upper brainstem, hypothalamus, thalamus

 Determines the level of arousal

 Cerebral hemispheres and interaction between functional areas in

cerebral hemispheres

 Determines the intellectual and emotional functioning

 Interaction between cerebral hemispheres and activating systems

Ascending RAS

 The ascending RAS, from the lower border of the pons to the
ventromedial thalamus

 The cells of origin of this system occupy a paramedian area in the

brainstem
Levels of arousal (consciousness)

 Conscious: alert, attentive and cooperative, awareness of self

and environment
 Confused: conscious but talks irrelevantly
 Drowsy: sleepy but can be aroused easily by external stimulus
 Stupor: Deep sleep, can only be aroused by painful stimulus
 Coma: unconsious, no response to external stimuli
AVPU scale

 Alert: The patient is awake

 Verbal: The patient responds to verbal stimulation
 Pain: The patient responds to painful stimulation
 Unresponsive: The patient is completely unresponsive

EMS crews may begin with AVPU assesment, to be

followed by GCS if the score is below "A."
 Glasgow Coma Scale (GCS)
Best eye Best verbal Best motor
response (E) response (V) response (M)
4 Eyes opening 5 Oriented 6 Obeys commands
spontaneously

3 Eye opening to 4 Confused 5 Localizes to pain

speech

2 Eye opening in 3 Inappropriate words 4 Withdraws from pain

response to pain

1 No eye opening 2 Incomprehensible 3 Flexion in response to

sounds pain

1 None 2 Extension to pain

1 No motor response
 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

 Generally, comas are classified as:

 Severe, with GCS ≤ 8

 Moderate, GCS 9 - 12

 Minor, GCS ≥ 13.

Differential Diagnosis of Coma
Differential Diagnosis of Coma

1. No focal neurologic signs, CT scan and cellular

content of the CSF are normal

2. Focal neurological signs, with or without changes in

the CSF; CT and MRI are abnormal

3. Meningitis syndromes, with an excess of WBCs in the

CSF, usually without focal signs; CT or MRI shows no
mass lesion
Diseases without focal neurological signs

Diseases that cause no focal or lateralizing neurologic signs,

usually with normal brainstem functions; CT scan and cellular
content of the CSF are normal
a. Intoxications: alcohol, sedative drugs, opiates, etc.
b. Metabolic disturbances: anoxia, hyponatremia, hypernatremia,
hypercalcemia, diabetic ketoacidosis, hypoglycemia, uremia,
hepatic coma, hypercarbia, Addisonian crisis
c. Severe systemic infections: septicemia, typhoid fever, malaria
d. Shock from any cause
e. Postseizure states, status epilepticus, nonconvulsive status
epilepticus
f. Hypertensive encephalopathy, eclampsia
g. Severe hyperthermia, hypothermia
Diseases with focal neurological signs

Diseases that cause focal brainstem or lateralizing cerebral

signs, with or without changes in the CSF; CT and MRI are
abnormal
a. CNS hemorrhage or infarction
b. Brain abscess, subdural empyema
c. Brain tumor with surrounding edema
d. Brain trauma: Epidural and subdural hemorrhage, brain
contusion
e. Metabolic coma (see above) with preexisting focal damage
f. Miscellaneous: Cortical vein thrombosis, herpes simplex
encephalitis, septic emboli due to bacterial endocarditis, acute
disseminated encephalomyelitis, thrombotic thrombocytopenic
purpura, cerebral vasculitis
Meningitis syndromes

Diseases that cause meningeal irritation with or without fever,

and with an excess of WBCs or RBCs in the CSF, usually without
focal or lateralizing cerebral or brainstem signs; CT or MRI shows
no mass lesion
a. Subarachnoid hemorrhage from ruptured aneurysm,
arteriovenous malformation, trauma
b. Acute bacterial meningitis
c. Viral encephalitis
d. Miscellaneous: fat embolism, cholesterol embolism,
carcinomatous and lymphomatous meningitis
Approach to Coma
 Approach to Coma

 General examination: On arrival to ER immediate attention to:

 Airway

 Breathing

 Circulation

 establishing IV access

 Blood should be withdrawn: estimation of glucose # other

biochemical parameters # drug screening

 Approach…
 Attention is then directed towards:

 Assessment of the patient

 Severity of the coma

 Diagnostic evaluation

 All possible information from:

 Relatives

 Paramedics

 Ambulance personnel

 Bystanders particularly about the mode of onset

History
1. The circumstances and rapidity with which neurologic
symptoms developed

2. The antecedent symptoms (confusion, weakness,

headache, fever, seizures, dizziness, double vision, or
vomiting)

3. The use of medications, drugs, or alcohol

4. Chronic liver, kidney, lung, heart, or other medical

disease
 Approach…
 Clues obtained from the patient's

 Clothing or

 Handbag

 Careful examination for

 Trauma requires complete exposure and ‘log roll’ to

examine the back

 Needle marks
Approach…

 If head trauma is suspected, the examination must await adequate

stabilization of the neck.

 Glasgow Coma Scale: the severity of coma is essential for

subsequent management.

 Following this, particular attention should be paid to brainstem

and motor function.

Examination of Comatose
General exam…

Pulse

 Bradycardia: brain tumors, opiates, ICT, myxedema

 Tachycardia: sepsis, hyperthyroidism, uremia

Blood Pressure

 High: hypertensive encephalopathy

 Low: Addisonian crisis, alcohol, barbiturate, MI, sepsis

General exam…
Temperature

 Fever in sepsis, meningitis, encephalitis, heat stroke,

anticholinergic drug intoxication

 Hypothermia in alcohol, barbiturate, sedative intoxication;

hypoglycemia, peripheral circulatory failure

Respiratory rate

 Tachypnea in acidosis or pneumonia

 Aberrant respiratory patterns in brainstem disorders

General exam…

Skin

 Injuries, Bruises: traumatic causes

 Dry Skin: DKA, Atropine

 Moist skin: Hypoglycemic coma

 Cherry-red: CO poisoning

 Needle marks: drug addiction

 Rashes: meningitis, endocarditis

General exam…

Odour of breath

 Acetone: DKA

 Fetor Hepaticus: in hepatic coma

 Urineferous odour: in uremic coma

 Alcohol odour: in alcohol intoxication

Level of Arousal

 Tickling the nostrils with a cotton wisp is a moderate

stimulus to arousal

 Pressure on the knuckles or bony prominences and

pinprick stimulation are humane forms of noxious
stimuli

 Pinching skin causes unsightly ecchymoses and is

generally not necessary but may be useful in eliciting
abduction withdrawal movements of the limbs
Posturing

Decorticate rigidity
 Flexion of the elbows and wrists and supination
of the arm
 Bilateral damage rostral to midbrain

Decerebrate rigidity
 Extension of the elbows and wrists with
pronation
 Damage to motor tracts in the midbrain or
caudal diencephalon
Posturing
Brainstem Reflexes

The brainstem reflexes that are examined are

1. Pupillary reflex

2. Ocular movements

3. Corneal reflex

4. Respiratory pattern

 As a rule, coma due to bilateral hemispheral

disease preserves these brainstem activities
Pupils

Pupils

 Size, inequality, reaction to a bright light.

 An important general rule: most metabolic encephalopathies give

small pupils with preserved light reflex.

 Atropine, and cerebral anoxia tend to dilate the pupils, and

opiates will constrict them.

Pupils

Reactive and round pupils of midsize (2.5–5 mm)

essentially exclude midbrain damage
Pupils
Structural lesions are more commonly associated with pupillary
asymmetry and with loss of light reflex.

 Midbrain lesions : round, regular, medium-sized pupils, do not

react to light

 Cranial nerve III distal to the nucleus: Ipsilateral fixed, dilated

pupil

 Pontine lesions: bilaterally small pupils, {in pontine hge, may be

pinpoint, although reactive}
Pupils

 Lateral medullary lesion: ipsilateral Horner's syndrome.

 Occluded carotid artery causing cerebral infarction: Pupil on that

side is often small

 Diencephalons

Small, reactive

Midbrain

Medium-sized, fixed Dilated, Fixed

Pons

Ipsilateral dilated, small, pinpoint

Fixed In hge reactive
.
Ocular movements

 The position of the eyes at rest

 Presence of spontaneous eye movement

 The reflex responses to oculocephalic and oculovestibular

maneuvers

 The eyes look toward a hemispheral lesion and away from a

brainstem lesion.
The oculocephalic reflex

 The oculocephalic reflexes, elicited by moving the head from side

to side or vertically and observing eye movements in the direction
opposite to the head movement
 If the eyes move conjugately in the opposite direction to that of
head movement, the response is positive and indicates an intact
pons mediating a normal vestibulo-ocular reflex
 The “doll’s eyes” refers to the reflex elevation of the eyelids with
flexion of the neck

 These reflexes are normally suppressed in the awake patient

The oculocephalic reflex
The oculovestibular reflex

 These are tested by the installation of ice-cold water into the

external auditory meatus, having confirmed that there is no
tympanic rupture.

 A normal response in a conscious patient is the development of

nystagmus with the quick phase away from the stimulated side
This requires intact cerebropontine connections
The oculovestibular reflex
Respiration
 Cheyne–Stokes respiration: (hyperpnoea alternates with apneas)
is commonly found in comatose patients, often with cerebral
disease, but is relatively non-specific.

 Rapid, regular respiration is also common in comatose patients

and is often found with pneumonia or acidosis.
Respiration
 Central neurogenic hyperventilation

 Brainstem tegmentum (mostly tumors):

 ↑ PO2, ↓ PCO2, and

 Respiratory alkalosis in the absence of any evidence of

pulmonary disease

 Sometimes complicates hepatic encephalopathy

Respiration

 Apneustic breathing

 Brainstem lesions Pons may also give with a pause at full

inspiration

 Ataxic:

 Medullary lesions: irregular respiration with random deep and

shallow breaths
 Cheyne-Stocks

Central Neurogenic Hyperventilation

Apneustic

Cluster

Ataxic
 Abnormal breathing patterns in
coma
Cheynes - Stokes

Central Neurogenic
Midbrain

Apneustic
Pons

Ataxic Medulla

ARAS
Motor function

 Particular attention should be directed towards asymmetry of tone

or movement.

 The plantar responses are usually extensor, but asymmetry is again

important.

 The tendon reflexes are less useful.

 The motor response to painful stimuli should be assessed carefully

(part of GCS)
Motor function

 Painful stimuli: supraorbital nerve pressure and nail-bed pressure.

Rubbing of the sternum should be avoided (bruising and distress

to the relatives)

 Patients may localize or exhibit a variety of responses, asymmetry

is important
Motor function

 Flexion of the upper limb

with extension of the lower
limb (decorticate response)
and extension of the upper
and lower limb (decerebrate
response) indicate a more
severe disturbance and
prognosis.
Signs of lateralization
 Unequal pupils

 Deviation of the eyes to one side

 Facial asymmetry

 Turning of the head to one side

 Unilateral hypo-hypertonia

 Asymmetric deep reflexes

 Unilateral extensor plantar response (Babinski)

 Unilateral focal or Jacksonian fits

Meningeal irritation signs

1. Neck rigidity

2. Kernig’s sign

3. Brudzinski’s sign
Head and Neck
Head and neck

 The head

 Evidence of injury

 Skull should be palpated for depressed fractures.

 The ears and nose: haemorrhage and leakage of CSF

 The fundi: papilloedema or subhyaloid or retinal haemorrhages

Diagnostic Testing
Laboratories

 Obtain ABG, serum electrolytes, glucose, creatinine,

complete blood count, liver functions and urinalysis

 Drug levels ordered if appropriate

 Toxicology screen of blood and urine if suspected
Imaging

 A head CT should be obtained to evaluate for structural

abnormalities

 Brain MRI can be useful if head CT is nondiagnostic and

there is suspicion for an ischemic or parenchymal
lesion (especially of the posterior fossa)
Diagnostic Procedures
Cerebrospinal fluid (CSF) examination

 Lumbar puncture (LP) considered in patients with fever

and/or new headache
 A fundus examination and/or head imaging prior to LP
to assess risk of herniation

 Basic cerebrospinal fluid (CSF) studies (e.g. protein,

glucose, cell count, Gram stain, and aerobic culture)
obtained with additional studies depending on the
possible etiology
Electroencephalography (EEG)

 Electroencephalography (EEG) to rule out seizures

 Nonconvulsive status epilepticus is a common cause of

unexplained encephalopathy in the critically ills
Elevated Intracranial Pressure
Treatment of Elevated ICP

 Insert ICP monitor—ventriculostomy versus

parenchymal device

 General goals: maintain ICP <20 mmHg and

CPP ≥60 mmHg
Treatment of Elevated ICP
1. Elevate head of the bed; midline head position
2. Drain CSF via ventriculostomy (if in place)
3. Osmotherapy—mannitol or hypertonic saline
4. Glucocorticoids—for vasogenic edema from tumor,
abscess
5. Hyperventilation—to PaCO2 30–35 mmHg
6. Pressor therapy— dopamine or norepinephrine to
maintain adequate MAP to ensure CPP ≥60 mmHg
7. Second-tier therapies for refractory elevated ICP
a. Decompressive craniectomy
b. High-dose barbiturate therapy (“pentobarb coma”)
c. Hypothermia to 33°C
Prognosis
Prognosis in coma

 In general, coma carries a serious prognosis

 This is dependent to a large extent on the underlying cause

 Coma due to depressant drugs carries an excellent prognosis

provided that resuscitative and supportive measures are available
and no anoxia has been sustained

 Metabolic causes, apart from anoxia, carry a better prognosis than

structural lesions and head injury
Prognosis in coma

 Length of coma and increasing age are of poor prognostic

significance.

 Brainstem reflexes early in the coma are an important predictor of

outcome