Comma

Diagnosis of Coma
Anna Karpenko, MD*, Joshua Keegan, MD
KEYWORDS
Coma Neurocritical care Disorders of consciousness
KEY POINTS
The differential diagnosis for the comatose patient is broad and includes structural abnor-
mality, seizure, encephalitis, metabolic derangements, and toxicologic etiologies.
Obtaining a good collateral history and physical examination are imperative for identifying
the correct diagnosis.
We discuss the diagnostic testing and treatment considerations for each cause of coma.
INTRODUCTION
Coma may be defined as a state of prolonged unresponsive unconsciousness. As

such, it is not a disease process, but rather a symptom that may be caused by a variety
of disease processes. Causes include structural, metabolic, toxicologic, and infec-
tious etiologies; prognosis varies substantially with the underlying cause. The common
pathway resulting in coma is thought to include disruption of neuronal function or
pathways from the ascending reticular activating system through the thalami to the
cortex.1 It is important to note that only lesions affecting the ascending reticular acti-
vating system or bilateral hemispheres result in coma and coma should never be
attributed to unilateral cortical lesions.
Coma is by definition a medical emergency, because it impairs the patient’s ability
to protect the airway; many underlying causes of coma are also independently emer-
gent. In a study of International Classification of Diseases, 9th edition, codes, coma
was responsible for 29 emergency department visits per 100,000 population,2 a
decreasing number that likely represents under-reporting as emergency department
workup to identify an underlying cause is improving.
Treatment of coma is targeted toward immediate stabilization, identification in
particular of reversible underlying etiologies, and correcting alterations in normal
physiologic processes. This article contains a differential diagnosis for coma etiol-
ogies, prioritized by acuity and reversibility, along with suggested diagnostic and sta-
bilization strategies. In all cases, information obtainable from the patient will be limited,
Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
* Corresponding author.
E-mail address: Anna.Karpenko@hitchcock.org
Emerg Med Clin N Am 39 (2021) 155–172

https://doi.org/10.1016/j.emc.2020.09.009 emed.theclinics.com
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156 Karpenko & Keegan
and consequently the initial differential must be formed on the basis of historical infor-
mation from surrogates and physical examination.
HISTORY AND PHYSICAL EXAMINATION PEARLS

History
The patient’s history should provide the majority of information needed to narrow the
diagnosis. In addition to knowing the right questions to ask, knowing the order in
which to ask them will help to triage the patient and to formulate a plan at the same
time. In some cases collateral information will be unavailable resulting in reliance solely
on physical examination and ancillary testing.
Acuity and onset
Was the change sudden?
Was the patient showing earlier signs such as excessive sleepiness, confusion,
or memory problems before coma onset?
Was the patient experiencing other symptoms such as fevers, unusual move-
ments, weakness, numbness or tingling, headaches, light sensitivity, or neck
or back pain?
What was the patient doing when this occurred?
When was the last time seen in their usual state of health?
History of brain surgery?
Vascular risk factors
Hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease,
smoking history, obstructive sleep apnea, atrial fibrillation, history of stroke
or intracerebral hemorrhage, family history of aneurysms, or history of throm-
bosis or thromboembolism?
Seizure risk factors
Personal or family history of seizures or status epilepticus?
Febrile seizures as a child?
History of head trauma with loss of consciousness?
History of central nervous system infection?
History of psychiatric disease?
History of depression or suicidal ideations?
Prescribed psychiatric medications?
Compliant with medications?
When was the last refill and how much is left?
History of substance abuse?
Which substances?
How much?
Use of injectable drugs?
Physical Examination
Vital signs
Tachycardia is nonspecific and may reflect hemodynamic compromise. The patient
may have an elevated heart rate owing to pain, seizure, or intoxication with an adren-
ergic or anticholinergic substance. Rapid atrial fibrillation may be reactive but should
raise concern for ischemic stroke as the cause of altered sensorium.
Bradycardia may result in cerebral hypoperfusion when associated with relative hy-
potension. Additionally, particularly when seen in conjunction with hypertension and
decreased or irregular breathing, known as Cushing’s triad, it may signify elevated
intracranial pressure.
Coma 157
Hypertension, similarly, may directly cause encephalopathy and thus leads to a

diagnosis of hypertensive emergency. However, hypertensive encephalopathy is usu-
ally relatively mild and the diagnosis should be reached only after excluding other
acute processes. In acute brain injury blood pressure is augmented by the brain’s
intrinsic autoregulatory mechanism to maintain cerebral blood flow. Hypertension
can also be seen in patients with seizures or those with ingestion of adrenergic or anti-
cholinergic substances.
Hypotension may result in cerebral hypoperfusion and coma. It is otherwise a
nonspecific finding with a broad differential diagnosis, including various forms of
end-organ dysfunction such as shock, end-stage kidney disease, or end-stage liver
disease. It may also be seen in the setting of opiate, barbiturate or benzodiazepine
intoxication, overdose of antihypertensive medication, or loss of sympathetic tone
from a spinal cord injury.
Tachypnea may be a central phenomenon known as central neurogenic hyperven-
tilation, occurring in response to a lesion in the midbrain or diencephalon. However,
tachypnea is more frequently a result of a primary pulmonary process, a pain
response, or as compensation for a metabolic acidosis as seen in sepsis and drug
intoxication (Kussmaul’s breathing).
Apnea or irregular breathing patterns, when central in origin, have multiple variants
including:
Cheyne–Stokes respirations: Periods of “crescendo–decrescendo” tachypnea
with periods of apnea, which can be seen in metabolic encephalopathy, supra-
tentorial lesions, and lesions of the midbrain or diencephalon.
Apneustic: Prolonged inspiration and expiration separated by periods of apnea,
which can be seen in pontine lesions.
Ataxic (Biot’s): Periods of tachypnea and apnea lacking the crescendo–
decrescendo quality of Cheyne–Stokes respirations and is associated with le-
sions in the medulla. This breathing pattern usually carries a poor prognosis.
Additional examination findings
Hiccups may be seen with medullary lesions. Additionally, outside of gastrointestinal
disease, vomiting may be indicative of hydrocephalus with increased pressure to the
area postrema located on the floor of the fourth ventricle.
Head, Eyes, Ears, Nose, and Throat

Fundoscopic examination may show papilledema suggestive of elevated intracra-
nial pressure. Presence of retinal hemorrhage or detachment is suggestive of
head trauma. Periorbital ecchymosis (“raccoon eyes”), mastoid ecchymoses (“Bat-
tle’s sign”), and hemotympanum are concerning for basal skull fracture. Dry
mucosal membranes may be a result of dehydration or intoxication with antidepres-
sants, anticholinergics, neuroleptics, antihistamines, muscle relaxants, seizure
medications, or antihypertensives. Conversely, excessive salivation, lacrimation,
and diaphoresis can point to cholinergic intoxication. Finally, scleral icterus may
be a sign of end-stage liver disease or hepatic encephalopathy with or without ce-
rebral edema.
Neurologic Examination
Pupils
Anisocoria is present in the general population and may be a benign finding, especially
if reactivity is intact. A unilateral dilated and nonreactive pupil may suggest uncal her-
niation with compression of cranial nerve III, or a midbrain lesion affecting the third
nerve nucleus. Abnormal pupillary constriction or dilation can be caused by medica-

tions with adrenergic or cholinergic effects. When accompanying coma, miotic
(“pinpoint”) pupils most commonly indicate intoxication with opiates or benzodiaze-
pines, cholinergic substances such as organophosphates, or a structural lesion in
the pons. Bilateral dilated pupils with decreased or absent pupillary constriction
may be indicative of a severe diffuse cerebral process; however, this finding can
also be found in profound intoxication, sedation, or hypothermia (Table 1).
Extraocular motion
Vestibulo-ocular reflex Loss of this reflex suggests an abnormality in the brain stem or
higher cortical function, but is nonspecific in etiology. This condition can be assessed
with oculocephalic maneuver or cold caloric testing. Forced gaze deviation or gaze
preference involves functional disruption for the frontal eye fields. The patient will
gaze toward the side of stroke or away from the seizure focus. Dysconjugate gaze
is generally nonspecific for diagnostic purposes, although skew deviation is a vertical
misalignment of the eyes and is a sign of a brain stem or cerebellar lesion. Although
unilateral nystagmus may be seen in peripheral vestibular disease, when it is bidirec-
tional, vertical or rotatory, and nonfatiguing, it is indicative of a cerebellar or brain stem
lesion or substance intoxication such as phencyclidine. A downward fixed gaze, also
known as “setting sun sign,” is caused by a midbrain lesion (Parinaud syndrome).
Ocular bobbing is associated with pontine lesions.
Other cranial nerve findings

Absence of the corneal, cough, or gag reflexes is another sign of severe diffuse cere-
bral dysfunction, but the etiology is nonspecific. Central facial asymmetry, in which
eyebrow raise is preserved, is seen with cortical or subcortical injury. Head version
may be indicative of a focal seizure originating from the contralateral hemisphere.
Motor and sensory findings

In comatose patients, the sensory portion of the neurologic examination is limited to
their response to stimulation, which is performed during the motor examination.
Increased tone or rigidity can indicate serotonin syndrome, neuroleptic malignant syn-
drome, malignant hyperthermia, subacute or chronic brain injury, seizure, or chronic
spinal cord injury. Spontaneous and purposeful movement is often times a reassuring
finding. Response to noxious stimulation in the upper extremities can be categorized
as either localization, withdrawal, decorticate, or decerebrate posturing. Response to
noxious stimulation in the lower extremities can be categorized as either spontaneous,
withdrawal, or triple flexion. Triple flexion is a nonsustained, stereotyped flexion at the
hip, knee, and ankle and is a brain stem–mediated response reflecting a loss of cortical
involvement. Absence of motor responses is nonspecific and could indicate organic
disease or other severe metabolic disease or intoxication.
Reflex testing
Hyperreflexia or clonus may be seen as part of serotonin syndrome, neuroleptic ma-
lignant syndrome, malignant hyperthermia or tetanus. Hyporeflexia may be seen in
acute brain or spinal cord injury or a neuromuscular process such as botulism.
DIFFERENTIAL DIAGNOSIS
Structural Causes
It is critical in patients with undifferentiated coma to exclude structural causes,
because they form some of the most acute and in many cases very treatable causes
of coma. Broadly speaking, structural causes of coma can be grouped into vascular
Coma 159
Table 1
Abnormal eye findings and causes
Bilateral miosis Opiates

“pinpoint pupils” Benzodiazepines
Barbiturates
Cholinomimetic substances (pilocarpine, carbachol, etc.)
Cholinesterase inhibiters (neostigmine, organophosphates, etc)
Clonidine
Phenothiazine
Ergot derivatives
Pontine lesion
Bilateral mydriasis Anticholinergics (atropine, diphenhydramine, scopolamine)
Sympathomimetics (cocaine, methamphetamines, MDMA, dopamine,
phenylephrine, norepinephrine)
Serotonergics (selective serotonin reuptake inhibitors, psilocybin,
d-lysergic acid diethylamide, dextromethorphan)
Opioid or benzodiazepine withdrawal
Oxytocin
Increased intracranial pressure with bilateral cranial nerve III
compression (nonreactive)
Botulinum toxin
Post-traumatic iridoplegia
Diabetic neuropathy
Anisocoria May be a normal finding, especially if minimal difference in size
and both reactive
Unilateral cranial nerve III compression (herniation)
Midbrain lesion affecting the cranial nerve III nucleus
Posterior communicating artery aneurysm
Horner’s syndrome
Adie’s tonic pupil
Post-traumatic irido plegia
Diabetic neuropathy
Conjugate gaze Structural lesion involving the frontal lobe ipsilateral to direction
deviation of gaze
Rarely, can be caused by pontine lesion
Seizure involving the frontal lobe contralateral to direction of gaze
Skew Brain stem or cerebellar lesion
Nystagmus Bidirectional and sustained, vertical or rotatory - brain stem or

cerebellar lesion
Sunset Sign Loss of vertical gaze - dorsal midbrain lesion or hydrocephalus
Ocular bobbing Extensive pontine lesion, associated with poor prognosis
lesions, space-occupying lesions, and lesions causing diffusely elevated intracranial

pressure through cerebrospinal fluid outflow obstruction. Some lesions may span mul-
tiple categories, such as a space-occupying intracranial hemorrhage owing to a
ruptured arteriovenous malformation.
All patients presenting with coma should undergo an emergent head computed to-
mography (CT) scan to exclude space-occupying structural lesions and hydrocepha-
lus; this is especially true for those with focal neurologic deficits, such as cranial nerve
findings. The decision to perform neuroimaging must be made on clinical grounds and
not delayed for results of laboratory testing, because many identifiable structural
causes require time-critical treatment.
Comatose patients will have a decreased intrinsic ability to maintain their airway,
and most will require intubation to ensure safety for neuroimaging. Any with overt ev-
idence of elevated intracranial pressure such as a herniation syndrome warrant
empiric osmotic therapy before neuroimaging, especially since this imaging requires
prolonged supine positioning.
The identification of a discrete space-occupying lesion will usually require specialist
consultation, because classification into operative versus nonoperative lesions is
beyond the scope of most emergency medicine practitioners. Any lesion causing sub-
stantial mass effect, herniation, or suspicion for globally elevated intracranial pressure
should be treated with osmotic therapy such as mannitol or hypertonic saline while
awaiting neurosurgical consultation. If this situation requires central line placement,
the subclavian site is preferred to limit potential obstructions of cerebral venous
outflow. Steroid administration should be reserved for vasogenic edema owing to un-
derlying tumor and is not recommended for edema surrounding hemorrhages.3,4 Hy-
drocephalus severe enough to result in coma, particularly if caused by intraventricular
hemorrhage or cerebrospinal fluid outflow obstruction, will likely require emergent
endoventricular drain placement by neurosurgery. It should be mentioned that proce-
dural management of infratentorial lesions is controversial and may include either
endoventricular drain or suboccipital decompression at the discretion of the neurosur-
gical team.
If an intracranial hemorrhage is diagnosed, reversal of anticoagulation is recom-
mended. Reversal of antiplatelet agents for intraparenchymal hemorrhages has
been shown to double the risk of death or dependency5 and has therefore been
removed as a routine practice recommendation.5 This development does not
mean to imply that specific individual patients (such as those with active arterial
bleeding or undergoing neurosurgical procedures) may not derive some benefit. A
cornerstone of management of intracranial hemorrhage is careful management of
blood pressure. A goal of systolic blood pressure is controversial, although targeting
to less than 160 has been shown to decrease hematoma expansion without signifi-
cant repercussions to renal function.6,7 There is no evidence for the use of prophy-
lactic antiepileptic drugs. Last, in patients with intracranial hemorrhage identified on
noncontrast CT scan, CT angiography may identify a responsible neurovascular
lesion warranting intervention.
Neurovascular etiologies of coma warrant specific discussion owing to their time-
sensitive and treatable nature. Basilar system thrombosis carries an extremely poor
untreated prognosis, and in the neurointerventional era has time-critical and poten-
tially effective treatments. The sensitivity of a noncontrast head CT scan for basilar
thrombosis has been reported to be as high as 50% to 70%8,9 with high clinical pretest
probability and when reviewed by expert neuroradiologists. In many clinical scenarios
even this moderate sensitivity will not be achievable, and consequently CT angiog-
raphy is increasingly becoming a standard diagnostic evaluation for comatose
Coma 161
patients and especially those with cranial nerve findings. Identifying acute basilar clot
has significant impact on outcomes, with 45% to 46%10,11 of those treated via endo-
vascular therapy having good outcomes (modified Rankin Scale of 0–2, functional in-
dependence) versus an untreated historical norm of approximately 10%.
In some cases, pontine injury may cause locked-in syndrome, which can be difficult
to differentiate from coma. In this syndrome, motor function is impaired but sensory
function and consciousness are preserved; patients may be able to use their eyes
to communicate and have variably preserved cranial nerve function depending on
the exact level of the lesion. Careful attention to cranial nerve and particularly the oc-
ulomotor components of the examination will ensure that locked-in syndrome is not
mistaken for coma. Although most strokes causing acute coma are basilar in nature,
there are uncommon supratentorial causes as well. These by necessity must be bilat-
eral, and may include strokes affecting multiple territories. Possible etiologies include
cardioembolic strokes as well as strokes arising from the artery of Percheron, which is
an anatomic variant in which the arterial supply of the bilateral paramedian thalami
arises unilaterally.
Depending on local institutional practices and resources, MRI may be considered in
the evaluation of structural causes of coma. This modality may be particularly helpful
in identifying brain stem pathology, including early infarction in the absence of overt
large vessel occlusion, as well as diffuse axonal injury from traumatic brain injury. In
most cases, this determination will not result in an immediate treatment change and
so may be deferred in many institutions; however, early identification of brain stem
infarct may obviate a comprehensive search for other etiologies, inform code status
discussions, and change disposition (ie, medical intensive care unit for undifferenti-
ated coma vs neurologic intensive care unit for infarct vs trauma or neurotrauma inten-
sive care unit for diffuse axonal injury or traumatic brain injury) (Table 2).
Nonconvulsive Status Epilepticus Versus Postictal State
Status epilepticus is defined as at least 5 minutes of clinical or electrographic seizure
activity, or multiple seizures without a return to neurologic baseline. Status epilepticus
is further divided into convulsive or nonconvulsive. Generalized convulsive status epi-
lepticus is characterized by tonic or tonic–clonic movements accompanied by an
altered mental status. In contrast, nonconvulsive status epilepticus does not have
obvious signs suggesting prolonged seizures, but rather is defined electrographically.
Patients with nonconvulsive status epilepticus may have subtle signs of seizures such
as facial or extremity twitching, eye deviation or nystagmus, or it may manifest only as
an abnormal mental status. Alternatively, the patient may present with agitation, apha-
sia, staring, confusion or coma.
Uncontrolled generalized convulsive status epilepticus may transition into noncon-
vulsive status epilepticus; therefore, timely recognition and treatment are essential.
Table 2
Structural causes of Coma
Ischemic Hemorrhagic Other

Bilateral anterior Subarachnoid hemorrhage Traumatic brain injury
cerebral artery Thalamic hemorrhage Hydrocephalus
strokes Pontine hemorrhage Midbrain tumor
Basilar occlusion Central pontine myelinolysis
Vasculitis Supratentorial mass causing herniation
Multiple sclerosis
Patients who present with nonconvulsive status epilepticus usually have underlying
comorbidities and are acutely ill. The differential of the inciting disease is broad and
includes toxic or metabolic derangements, infection, or structural brain lesions. Non-
convulsive status epilepticus is also generally more refractory to treatment.12
Diagnostic testing
A noncontrast CT scan of the head is standard of care to rule out acute structural eti-
ologies. MRI of the brain with and without contrast can be considered once the patient
has been stabilized.
An electroencephalogram (EEG) is the only definitive method of making the diagnosis
of nonconvulsive status epilepticus, and to differentiate nonconvulsive status epilepti-
cus from postictal state. Continuous EEG monitoring is preferred over routine EEG.
The duration of EEG monitoring is uncertain; however, for patients who have risk factors
for developing status epilepticus, 24 hours of monitoring should be considered.13
Laboratory testing should include glucose, basic metabolic panel, complete blood
count, lactate, and creatine kinase levels, which may be elevated in prolonged seizure.
Serum prolactin level is nonspecific for the diagnosis of status epilepticus; however, it
may be useful in differentiating patients with epileptic seizures from those with psy-
chogenic nonepileptic seizures if drawn at most 20 minutes from the time of seizure.14
Antiepileptic drug levels should be obtained when appropriate.
A lumbar puncture may be of value to acutely exclude central nervous system infec-
tion. It may also allow for testing of infrequent causes, such as autoimmune enceph-
alitis or occult malignancy when the etiology is uncertain. If a lumbar puncture is
performed in the setting of suspected or confirmed status epilepticus additional cere-
brospinal fluid should be banked to facilitate possible specialized testing.
Treatment
After initial stabilization and airway attainment, targeted therapy includes the
following. Benzodiazepines are the first-line treatment for status epilepticus. Intrave-
nous (IV) or intramuscular lorazepam or midazolam are preferred for their favorable
pharmacodynamics. Lorazepam should be dosed at 0.1 mg/kg, divided into multiple
doses to attenuate subsequent hypotension and respiratory depression. Similarly,
midazolam should be dosed at 0.2 mg/kg.
Concurrently, the patient should receive an antiepileptic drug, including:
Levetiracetam 1000 to 3000 mg
Minimal side effects
Lacosamide 200 to 400 mg
Minimal side effects
Phenytoin 20 mg/kg load, may repeat 5 to 10 mg/kg dose in 10 minutes
Phenytoin load may result in arrhythmias or hypotension; for this reason fos-
phenytoin is preferred
Valproate 20 to 40 mg/kg
Side effects include hepatotoxicity, thrombocytopenia, and pancreatitis
Phenobarbital 15 to 20 mg/kg
Side effects include hypotension and respiratory depression
If the patient continues to seize despite appropriate benzodiazepine dosing and at
least one antiepileptic drug, they are defined as having refractory status epilepticus. A
continuous infusion should be initiated and titrated to seizure suppression on EEG.
Propofol: Load with a 1 to 2 mg/kg bolus followed by infusion starting at 20 mg/
kg/min.
Coma 163
Side effects include hypotension, respiratory depression, and propofol infu-

sion syndrome including metabolic acidosis, rhabdomyolysis, cardiac and
renal failure.
Midazolam: 0.2 mg/kg dose followed by infusion starting at 0.05 to 2 mg/kg/h.
Side effects include hypotension and respiratory depression.
Pentobarbital: 5 to 15 mg/kg loading dose followed by continuous infusion at 0.5
to 5 mg/kg/h, at a maximum rate of 50 mg/min.
Side effects include hypotension, cardiac depression, respiratory depression,
and ileus.
The choice for preferred antiepileptic drug administration is a topic of debate,
although IV administration is vital for urgent seizure control. Traditionally phenytoin,
valproate, and phenobarbital were considered the agents of choice15 and were
selected based on their side effect profile and ease of administration. Newer agents
including levetiracetam, brivaracetam and lacosamide have since gained popularity
owing to their relatively lower incidence of side effects. A recent randomized clinical
trial16 was stopped early for futility and showed that levetiracetam was as efficacious
as phenytoin and valproate in aborting status epilepticus. Despite the excellent toler-
ability of brivaracetam and lacosamide, there is currently a paucity of strong evidence
to support their use in standard of care.
Encephalitis
Meningoencephalitis must be considered when a patient presents in a comatose
state. Both infectious and noninfectious etiologies should be reviewed and additional
history obtained to narrow the scope of treatment. Meningitis on its own does not
manifest with an altered mental status and presents instead with meningismus: head-
ache, neck stiffness, and photosensitivity. Encephalitis, in contrast, affects the brain
focally or diffusely and may present with a myriad of signs, including confusion, leth-
argy, personality changes, motor or sensory deficits, or seizures. Cerebritis describes
regionalized inflammation of the brain and is associated with infectious etiologies.
Immunosuppressed patients may have primary or coinfections with rare or atypical
diseases. Aseptic meningitis may include drug-induced, postinfectious or paraneo-
plastic etiologies (Table 3).
Diagnostic testing
A CT scan of the head may not be abnormal in meningitis or encephalitis, but may have
a localized area of hypodensity reflecting vasogenic edema surrounding an abscess. It
is also necessary to exclude a mass lesion to ensure safe lumbar puncture. An MRI of
the brain with and without contrast may be considered once the patient has been
treated empirically for potential reversible causes.
Routine serum laboratory tests may reveal a leukocytosis and lactic acidosis.
Lumbar puncture must be performed in a timely manner to isolate the offending
agent. Cerebrospinal fluid findings and their significance are listed in Table 4. Basic
cerebrospinal fluid studies include glucose, protein, cell count with differential, herpes
simplex virus polymerase chain reaction, varicella zoster virus polymerase chain reac-
tion and antibodies, cytomegalovirus polymerase chain reaction, Epstein–Barr virus
polymerase chain reaction, and bacterial culture. Opening pressure is important
because it can be suggestive of a specific underlying process. Additional studies
may be sent if atypical or rare infections are considered, or if there is concern for auto-
immune encephalitis.
An EEG should be performed to exclude nonconvulsive status epilepticus in coma-
tose patients with evidence of central nervous system infection (see Table 4).
164
Karpenko & Keegan

Table 3
Causes of Meningoencephalitis
Bacterial Viral Fungal Parasitic Autoimmune Drug Induced Other

Borrelia species Herpes simplex Aspergillus species Acanthamoeba Anti-AMPA Allopurinol Acute Disseminated
Escherichia coli Varicella zoster Blastomyces species Anti-Ampithysin Azathioprine Encephalomyelitis
Group B Cytomegalovirus dermatitidis Balamuthia Anti-ANGA Carbamezepine Carcinomatous
Streptococcus Epstein-Barr virus Candida species mandrillaris Anti-ANNA Cephalosporins meningitis
Haemophilus Human herpes Cocciodes immitis Naegleria Anti-CASPR2 Ciprofloxacin Central nervous
influenzae virus-6 Cryptococcus species fowleri system vasculitis
Klebsiella species Taenia solium Creutzfeldt–Jakob
Toxoplasma disease
gondii Fabry disease

Leptospira species Coxackie Histoplasma Trypanosoma Anti-CRMP Intrathecal Incomplete
Listeria Echovirus capsulatum brucei Anti-DPPX chemotherapy treatment of
monocytogenes Human Anti-GABA agents previous infection
Mycobacterium enteroviruses Isoniazid Lymphoma
tuberculosis Intravenous Neurosarcoidosis
immunoglobulin Progressive multifocal
Mycoplasma Rotavirus Anti-GAD65 Lamotrigine Leukoencephalopathy
pneumoniae Adenovirus Anti-GFAP Metronidazole
Neisseria Respiratory Anti-LGI1 Nnonsteroidal anti-
meningitidis syncytial virus Anti-mGluR1 inflammatory
Rickettsia species Rhinovirus Anti-NMDA drugs
Staphylococcus Influenza Anti-PCA Penicillins
aureus A and B Striated muscle Pyrazinamide
Streptoccocus Parainfluenza antibody Pyridium
pneumoniae viruses Sulfasalazine
Treponemia Human Trimethoprim–
pallidum immunodeficiency sulfamethoxazole
virus
Powassan virus
Colorado tick
fever virus
Western equine Bacterial Viral Fungal Parasitic Autoimmune

encephalitis
Venezuelan equine
encephalitis
St. Louis
encephalitis
Eastern equine
encephalitis
California
encephalitis
virus
La Crosse
encephalitis
West Nile virus
Human T-cell
lymphotropic
virus 1 and 2
Parvovirus
Hepatitis A and
B virus
Lymphocytic
choriomeningitis
Rabies virus
Measles
Mumps
Rubella
Coma
165
Table 4
Toxicologic causes of Coma
Environmental Drugs Metabolic

Carbon monoxide poisoning Alcohol Hypoglycemia
Hypothermia Benzodiazepines Hyperglycemia/diabetic ketoacidosis
Organophosphate poisoning Barbiturates Uremia
Opiates Hepatic encephaopathy
Anticholinergics Hypercalcemia
Toxic alcohols Hypocalcemia
Myxedema coma
Hypercapneic respiratory failure
Wernicke’s encephalopathy
Treatment
If there is suspicion for infectious cause, steroids and empiric antimicrobial medication
should be started without delay. For streptococcal meningitis, steroids have been
shown to reduce mortality if given before or with the initial dose of antibiotics.17
The recommended empiric regimen includes:
Dexamethasone 0.15 mg/kg every 6 hours for 2 to 4 days
Vancomycin: 15 to 20 mg/kg every 8 to 12 hours
Third generation cephalosporin:– for example, ceftriaxone 2 g every 12 hours
Acyclovir 10 mg/kg every 8 hours
If the patient is more than 50 years old or immunosuppressed, ampicillin should
be added for coverage of atypical organisms
If the patient has had a recent neurosurgical procedure, a fourth-generation
cephalosporin such as cefepime should replace the third-generation
cephalosporin
Fever should be treated to avoid secondary brain injury. Prophylaxis with antiseizure
medication is not recommended unless the patient has clinical or electrographic sei-
zures. Autoimmune encephalitides are treated acutely with high dose steroids (meth-
ylprednisolone 1 g/d for 5 days), intravenous immunoglobulin (2 g/kg divided over
5 days) or plasma exchange. Steroid-sparing agents may be considered if there is a
good clinical response to acute treatment.
Toxicologic Causes
Because coma may be caused by numerous toxins and laboratory identification of
them is time consuming and at times misleading (eg, having limited ability to differen-
tiate acute drug toxicity from recent ingestion), an initial differential diagnosis must be
formed and empiric therapy begun based solely on history and physical examination,
with urine toxicologic screens and other laboratory testing serving primarily purposes
of confirmation and assisting in longitudinal care. The more common, time-sensitive,
and treatable toxicologic causes of coma are discussed in detail elsewhere in this
article. A wide range of uncommon toxins exist and require supportive care while
seeking expert consultation (Table 5).
One of the most common and most immediately reversible etiologies is opiate
toxicity, in which case coma is usually accompanied by miosis and decreased respi-
ratory drive. Although most frequent in recreational drug users, iatrogenic opiate
toxicity, for example, among elderly patients with fluctuating renal function, should
also be considered. Clinicians should have a low threshold for administration of
Coma 167
Table 5
Cerebrospinal fluid findings
White
Opening Blood
Pressure Cell
(cmH2O) Glucose (mg/dL) Protein (mg/dL) Count Differential
Normal 5–20 >50 or 2/3 serum <50 <5 No differential
glucose
Bacterial Elevated <50 elevated >500 Neutrophilic
predominance
Viral Normal Normal Normal or slightly <1000 Lymphocytic
elevated predominance
Fungal or Elevated Normal or low Elevated <1000 Lymphocytic
tuberculosis predominance
Autoimmune Normal Normal Elevated <500 Lymphocytic
predominance
naloxone, a competitive opiate antagonist, because it has a benign side effect profile
and may help to avoid intubation. It should be noted that meperidine and propoxy-
phene result in mydriasis; naloxone administration should not be withheld solely on
the basis of this physical examination finding. Last, naloxone has a short half-life, often
shorter than that of the opiate itself, and especially in the context of an unknown opiate
ingestion patients must be monitored for recurrence of toxicity as the naloxone is
metabolized.
Benzodiazepines are another medication class with substantial potential to cause
coma, particularly in intentional/suicidal ingestions. Benzodiazepines taken in isolation
are rarely fatal and there are no pathognomonic physical examination findings18; sus-
picion must be based on historical clues. The main physical examination finding
consistent with benzodiazepine toxicity is depressed mental status, which may be
as severe as complete electroencephalographic silence on EEG. Compromised respi-
rations are possible but much less common than with opiate or barbiturate ingestions.
Flumazenil is a competitive antagonist that can be used to reverse cases of known
acute-only benzodiazepine toxicity, but should be avoided in cases of unknown or
chronic benzodiazepine administration to avoid precipitating potentially life-
threatening withdrawal and intractable seizures. Care in such cases is primarily sup-
portive while awaiting toxin metabolism.
Barbiturate ingestion presents similarly to benzodiazepine toxicity but with more
pronounced respiratory and cardiovascular suppression; no specific reversal agent
is available and care is supportive including mechanical ventilation and vasopressor
support.
Acute alcohol intoxication may result in coma when blood levels exceed 0.3%;
approximately 1% of all alcohol intoxication visits require critical care,19 which is
generally supportive and may include management of accompanying bradycardia
and hypotension. Rapid testing of exhaled breath levels or blood levels is commonly
available and may assist with risk stratification and disposition decisions. Rapid
testing for toxic alcohols such as methanol, ethylene glycol, and isopropyl alcohol is
largely unavailable; elevated osmolar gap and anion gap metabolic acidosis (in the
cases of methanol and ethylene glycol) should raise clinical suspicion. When clinical
suspicion exists, empiric administration of fomepizole, an alcohol dehydrogenase
inhibitor preventing breakdown to toxic metabolites, should be initiated while awaiting

confirmatory testing. Last, Wernicke encephalopathy has been reported to cause
reversible coma20,21 and thiamine should be administered empirically to comatose pa-
tients with suspicion of alcohol use disorders.
Severe carbon monoxide poisoning may also result in coma; again there are no
pathognomonic findings and high clinical suspicion must be maintained. Although
more common in the winter owing to higher home heating needs, 30% carbon mon-
oxide poisoning is intentional22 and may therefore occur at all times of the year.
Diagnosis is supported by pulse co-oximetry or laboratory spectrophotometry, but
owing to poisoning of the oxidative phosphorylation pathway symptoms may persist
after blood carbon monoxide levels have returned to baseline. As a result, normal
level should not be used to exclude toxicity in an appropriate clinical context.
When available and performed from the emergency department, MRI showing
restricted diffusion specifically in the region of the globus pallidus is strongly sup-
portive of carbon monoxide poisoning. Aside from supportive care, specific treat-
ment includes oxygen supplementation and consideration of hyperbaric oxygen
therapy.
Metabolic Causes
Hypoglycemia is one of the most common and most immediately reversible causes
of coma. Any patient presenting with coma should either have a fingerstick glucose
checked or empiric administration of dextrose (preceded by thiamine if the clinical
context suggests concurrent alcohol abuse). Patients who are chronically hypergly-
cemic may become symptomatic even with low-normal glucose levels. An underly-
ing explanation for hypoglycemia such as insulin overdose should always be
sought; in the case of accidental overdose of short-acting insulin, emergency
department observation and discharge may be all that is indicated, whereas pa-
tients with intentional overdoses, overdoses of long-acting insulin, and unexplained
hypoglycemia should be admitted for more prolonged monitoring and further
workup.
Hypercarbic respiratory insufficiency also frequently leads to depressed mental sta-
tus and coma. At times patients may present with clinically evidence hypoventilation
as a cause; pulmonary disease such as chronic obstructive pulmonary disease may
also play a less overt role. Given that venous carbon dioxide cannot be lower than
arterial carbon dioxide, a normal venous blood gas is sufficient to exclude clinically
significant hypercarbia. If the venous carbon dioxide is elevated an arterial blood
gas should generally be performed to confirm this finding. Although depressed mental
status is a contraindication to unsupervised biphasic positive airway pressure, cases
of hypercarbia attributed to neuromuscular disease or respiratory muscle fatigue may
benefit from a short-term (20–30 minutes) trial of biphasic positive airway pressure un-
der direct observation to determine if improved carbon dioxide clearance will result in
a mental status suitable for longer term biphasic positive airway pressure. Worsening
hypercarbia or failure of mental status changes to resolve should prompt intubation.
As opposed to neuromuscular causes, cases of central hypoventilation will generally
not respond to biphasic positive airway pressure and mechanical ventilation will be
required. Once hypercarbia has been resolved, patients should be reevaluated to
exclude additional contributors to coma (eg, opiate administration leading to
hypercarbia).
When severe, numerous electrolyte abnormalities may result in coma. Routine lab-
oratory evaluation should include serum electrolytes, including calcium and magne-
sium levels. Correction of identified abnormalities should be initiated in the
Coma 169
emergency department before admission; most patients will likely require inpatient
management. Evaluation for underlying causes of electrolyte abnormalities can gener-
ally be deferred to the inpatient setting. Last, although usually obvious from historical
or environmental clues, hypothermia may also result in coma and it should be ensured
that all comatose patients have a core temperature documented as part of their initial
evaluation.
Hepatic Encephalopathy
Any patient with history or clinical examination stigmata (such as jaundice or spider tel-
angiectasias) of liver disease presenting with coma should have an ammonia level
checked to determine if hepatic encephalopathy may be responsible. The pathogenesis
of hepatic encephalopathy is incompletely understood and the degree of hyperammo-
nemia does not directly correlate with degree of encephalopathy. Consequently, for
those with any ammonia elevation, treatment with lactulose should be initiated and
continued until clinical resolution of symptoms; rifaximin may be a useful adjunct and
is thought to decrease intestinal bacterial ammonia production. Contributing conditions
such as upper gastrointestinal tract bleeding should be identified and corrected. Admin-
istration of flumazenil may be considered because it has been shown to improve symp-
toms of hepatic encephalopathy, even in the absence of benzodiazepine use; however,
this effect may often be transient and no statistically significant effect on mortality has
been demonstrated.23
Endocrine
Thyroid dysfunction in the form of severe decompensated hypothyroidism can result
in an entity termed “myxedema coma.” This syndrome includes hypoactive delirium or
coma, hypoventilation, bradycardia, hypotension, hypothermia, thick coarse skin, and
thinning hair. Seizures may occur as well, especially in the setting of severe metabolic
derangements. It is important to also investigate precipitating factors such as infec-
tion, cold exposure, and recent trauma. An association exists between decompen-
sated hypothyroidism and intoxication with opioids or other classes of sedating
medications, as well as with amiodarone use.
Diagnostic testing
The mainstay of diagnosis is confirmatory thyroid function tests: serum thyroid-
stimulating hormone (elevated in primary hypothyroidism but reduced in secondary hy-
pothyroidism), free thyroxine (reduced). Cortisol is often decreased as a result of either
primary or secondary adrenal insufficiency and in this case cosyntropin stimulation test
may be helpful. Hypoglycemia may result from decreased gluconeogenesis and adrenal
insufficiency. Hyponatremia is usually a result of coexisting syndrome of inappropriate
diuretic hormone. Elevated creatine kinase and a reduced glomerular filtration rate may
be present. Furthermore, hypoxemia and hypercapnia may be seen on blood gas. The
electrocardiogram may show sinus arrhythmias and QT prolongation. Therefore, contin-
uous monitoring is recommended. Additionally, EEG monitoring should be performed to
exclude nonconvulsive status epilepticus. Lumbar puncture, if performed incidentally,
may have an elevated protein but is otherwise diagnostically nonspecific. There are usu-
ally no specific abnormalities seen on neuroimaging.
Treatment
Because incidence of myxedema coma is relatively low, there is clinical equipoise as
to the exact treatment regimen. Though traditionally a large dose of levothyroxine was
the preferred approach, there exist alternative regimens combining tri-iodothyronine
and thyroxine replacement. One such regimen is listed here.24
After appropriate laboratory testing has been drawn:

Levothyroxine 200 to 300 mg IV, followed by daily doses of 1.6 mg/kg
Tri-iodothyronine 10 to 25 mg IV, followed by 2.5 to 10 mg every 8 hours
Hydrocortisone 100 mg every 8 hours until exclusion of adrenal insufficiency
Supportive care including ventilator and circulatory support, passive rewarming
or IV dextrose as needed
Treatment of underlying infection
Treatment of arrhythmias
Psychogenic Causes
Psychiatric or psychological causes of coma may be considered once all medically
treatable conditions have been considered and addressed. Such causes include
catatonia, psychogenic nonepileptic seizures, conversion disorder, factitious disor-
der or malingering. The patient’s physical examination is the most telling diagnostic
test for these entities and consultation with an experienced neurologist may be
helpful.
THE FUTURE OF COMA
The Curing Coma Campaign was launched in 2019 and consists of a multidisciplinary
scientific advisory committee dedicated to furthering our understanding and treatment
of coma. The campaign is organized into 3 pillars. The first pillar includes classifica-
tion, or endotyping, of different types of coma based on pathophysiology. The second
pillar focuses on continuing investigation of neuroprognostic biomarkers, the refine-
ment of which would inform the treating clinician of the expected clinical recovery
for each endotype of coma. Finally, the third pillar centers on the efforts to implement
proof-of-concept trials targeted at pharmacologic and electrophysiologic interven-
tions to improve outcomes for patients with disorders of consciousness.25 This
concerted international mission holds the potential to advance our current prognosti-
cation practice patterns and to improve the long-term outcomes of comatose
patients.
DISCLOSURE
The authors have nothing to disclose.
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Diagnosis of Coma

Anna Karpenko, MD*, Joshua Keegan, MD

Coma may be defined as a state of prolonged unresponsive unconsciousness. As

Emerg Med Clin N Am 39 (2021) 155–172

HISTORY AND PHYSICAL EXAMINATION PEARLS

Hypertension, similarly, may directly cause encephalopathy and thus leads to a

Head, Eyes, Ears, Nose, and Throat

nerve nucleus. Abnormal pupillary constriction or dilation can be caused by medica-

Other cranial nerve findings

Motor and sensory findings

Bilateral miosis Opiates

Skew Brain stem or cerebellar lesion

Nystagmus Bidirectional and sustained, vertical or rotatory - brain stem or

Sunset Sign Loss of vertical gaze - dorsal midbrain lesion or hydrocephalus

Ocular bobbing Extensive pontine lesion, associated with poor prognosis

lesions, space-occupying lesions, and lesions causing diffusely elevated intracranial

Ischemic Hemorrhagic Other

 Side effects include hypotension, respiratory depression, and propofol infu-

Karpenko & Keegan

Bacterial Viral Fungal Parasitic Autoimmune Drug Induced Other

gondii Fabry disease

Western equine Bacterial Viral Fungal Parasitic Autoimmune

Environmental Drugs Metabolic

inhibitor preventing breakdown to toxic metabolites, should be initiated while awaiting

After appropriate laboratory testing has been drawn:

THE FUTURE OF COMA

The authors have nothing to disclose.

1. Edlow BL, Takahashi E, Wu O, et al. Neuroanatomic connectivity of the human

5. Baharoglu MI, Cordonnier C, Al-Shahi Salman R, et al. Platelet transfusion versus

195(5):596–606 [published correction appears in Am J Respir Crit Care Med.

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Side effects include hypotension, respiratory depression, and propofol infu-