COMA(UNCONSCIOUSNESS)

CHARLOTTE KIKUVI
 Definition
 Conscious
◦ Appearance of wakefulness, awareness of the self and
environment
 Fainting:
◦ It is a brief loss of consciousness that is caused by a
temporary reduction of blood flow to the brain.
 Semi coma
◦ Defined as complete loss of consciousness with a response
only at the reflex level
 Unconscious (coma)
◦ Sleep like appearance and behaviorally unresponsive to all
external stimuli
 Coma in Children
Coma:
 A state of unconsciousness from which a patient can’t be

aroused by ordinary external stimuli (ordinary pain, touch,

speech).
 depth of coma varies and may be scored as per the Glasgow

coma scale or Blantyre coma scale in <6yrs

 Symptoms:
 A brief loss of consciousness causing the casualty to fall to the
floor
 A slow pulse
 Pale, cold skin and sweating
Causes Of Unconciousness
Thiamine
deficiency

metabolic
Brain
disturbanc
tumor
es

Causes of
unconcious
ness

epilepsy trauma

Cardiovasc
infections ular
disease
 Causes of Coma
1.Trauma
◦ Non accidental injury (shaken baby syndrome)
◦ Accidents.
◦ Birth injuries.
2.Non traumatic
 i) Hypoxic ischemic encephalopathy.

◦ Near drowning.
◦ Perinatal asphyxia.
◦ Cardiorespiratory arrest.
◦ Suffocation.
 ii)CNS infection
◦ Meningitis/ encephalitis
◦ Brain Abscess/Tumours – cerebral / meningeal tumors
◦ malaria,
◦ typhoid,
◦ rabies,
◦ trypanosomiasis.
 Cont.
 iii) Metabolic disorders
◦ Hepatitis/ Renal failure (uraemia Encephalopathy)
◦ Hypoglycaemia / Hyperglycaemia/DKA/Electrolyte imbalance
◦ Acid – base imbalance / Shock
◦ Dehydration.
 Iv)Cerebro-vascular disorders
◦ Intracranial haemorrhage
◦ Vasculitis/ thrombosis
◦ Encephalopathy of sicklers.
 v) Seizures.
◦ Epilepsy – nonconvulsive status / postictal state
 vi) Endocrine abnormalities e.g. thyrotoxicosis.
 vii) Toxins/ poisons/ drugs
◦ Organophosphates/ carbamates /Carbon Monoxide
◦ Anticonvulsants and other drugs
◦ Alcohol
◦ Opiates
 viii) Structural & degenerative CNS disorders.
 Pathophysiology of coma
 Consciousness results from network neuronal activity linking
the cerebral hemispheres, the cerebellum, basal ganglia, and
thalamus.
 The ascending reticular activating system, the brain stem
arousal system, critical to alert state.
 Vegetative state arises from dysfunction of the cortex with a
normally functioning brain stem.
 Coma state is associated with variable changes in:
◦ pupillary size,
◦ ocular motility (evoked and spontaneous),
◦ motor responses and – respiration pattern.
 Eye Features in coma
 Ocular motility & pupillary size:
◦ Brainstem lesions and diffuse hemispheric lesions may abolish the
oculo-cephalic (doll’s head eye) and oculo-vestibular responses.
◦ Metabolic encephalopathy, diencephalic lesions and barbiturate
poisoning result in small constricted pupil responsive to bright light.
◦ Parasympathetic and sympathetic injury in the mid brain result in pupils
that are fixed in the midposition and non-reactive.
 Ocular motility & pupillary size:
•Oculomotor nerve injury (as in states of increased intracranial pressure
with tentorial herniation) causes fixed dilated pupil.
• Pinpoint pupils occur in
◦ – organophosphate poisoning,
◦ – pontine lesions and
◦ – narcotic poisoning
 Motor / Respiratory Features
 Motor responses:
◦ Are variable depending on site of lesion.
◦ Decerebrate posture may arise from diffuse cerebral lesions.
 Abnormal respiration include:
◦ Chyne stokes respiration (lower cerebral hemispheres
dysfunction, diencephalon or pons).
◦ Central neurogenic (hyperventilation): rostral brainstem
tegmentum pathologies.
◦ Ataxic breathing: medullary respiratory centre pathology.
◦ Cluster breathing: disorders of respiratory control centre in mid
or caudal pons. Manifests with episodic irregular respiratory
pattern Clinical evaluation of coma
 Clinical evaluation of coma
Glasgow Coma scale
 Eye opening

◦ Spontaneous---------------------- 4
◦ To speech------------------------- 3
◦ To pain---------------------------- 2
◦ No response---------------------- 1
 Motor response
◦ Spontaneous---------------------- 6
◦ Localizes pain-------------------- 5
◦ Withdraws to pain---------------- 4
◦ Abnormal flexion to pain-------- 3
◦ Abnormal extension to pain----- 2
◦ No response------------------------ 1
Cont.
 Best verbal response
◦ Orientated---------------------------5
◦ Confused----------------------------4
◦ Inappropriate-----------------------3
◦ Incomprehensible------------------2
◦ No response-------------------------1

 • Maximum score is 15, representing normal consciousness;

 • 12-14: Mild coma
 • 8- 11: moderate coma; and
 • Score of < 8 being deep/ severe coma.
 • The GCS correlates well with prognosis in traumatic coma
The Blantyre Coma Scale (The modified Glasgow
Coma scale) (for children < 12 years)
 • Eyes open
◦ spontaneously 1
◦ Eyes movement
 directed (eg follows mothers face) 1
 not directed 0
 • Verbal response
◦ appropriate cry 2
◦ moan or inappropriate cry 1
◦ none 0
 • Best motor response
◦ localizes painful stimulus 2
◦ withdraws limb from pain 1
◦ non-specific or absent response 0

 Total 0 - 5
 APPROACH
 ABC

 Immediate management

 Examination

 History

 Investigations
 1. ABC

ABC

A –Open C–
B–
the circulatio
breathing
airway n
 2. Immediate management
 Maintain i.v line,

 Oxygen inhalation

 Blood sample for RBS

 Control seizures

 Consider i.v glucose, thiamine, naloxone, flumazenil

 3. General physical Examination
i) Vital signs

ii) Evidence of trauma

iii) Evidence of acute or chronic system illness

iv) Evidence of drug ingestion ( needle marks alcohol breath )

v) Nuchal rigidity (examine with care)

 Examination

Examination

•Neurological
•Vitals
•Skin petechial assessment •Detailed medical
•Neck rigidity
rash •Fundoscopy examination
•Injection marks
•Brainstem reflexes
 Vitals
1.Pulse
Tachycardia
 Hypovolemia/haemorrhage
 hyperthermia
 Intoxication

Bradycardia
 Raised intracranial pressure
 Heart blocks
Cont.
2.Temperature
Increased
 Sepsis
 Meningitis ,encephalitis
 Malaria ,Pontine haemorrhage

Decreased
 Hypoglycemia
 Hypothermia (less than 31 C)
 Myxedema
 Alcohol, barbiturate ,sedative or phenothiazine intoxication.
Cont.
3.Blood pressure
Increased
 Hypertensive encephalopathy
 Cerebral haemorrhage
 Raised intracranial pressure

Decreased
 Hypovolemia /hemorrage
 Myocardial infarction
 Intoxication/poisoning
 Profound hypothyroidism, Addisonian crisis
Cont.
4.Respiratory rate
Increased(tachypnae)
 Pneumonia
 Acidosis (DKA, renal failure)
 Pulmonary embolism
 Respiratory failure

Decreased
 Intoxication/poisoning
 Neurological assessment
 General posture
◦ Lack of movements on one side
◦ Intermittent twitching
◦ Multifocal myoclonus
◦ DECORTICATION
◦ DECEREBRATION
 Level of consciousness
Glasgow coma scale (GCS)
• Best motor response
• Best verbal response
• Eye opening
• GCS score 3 –severe injury
• less than or equal to 8 – moderate injury
• 9 to 12 – minor injury
 AVPU
An abbreviated coma scale is used in the assessment of
critically ill patient (primary servey)
A –Alert
V – Respond to voice stimulus
P – Respond to pain
U - Unresponsive
 4. History
i) Onset of coma
(abrupt, gradual)

ii) Recent complaints

( headache, depression, focal weakness, vertigo, Fever,
vomiting, seizures)

iii) Recent injury/trauma

iv) Previous medical illness

( diabetes,uraemia, heart disease )

v) Access to drugs
( sedatives,psychotropic drugs, poisoning, drug injestion )
 5. Immediate investigations
 Blood sugar
 Haemogram
 Electrolytes/ Urea Nitrogen
 LFTs
 Blood gases
 BS for MPS
 CSF analysis
 Urine examination
 Blood/ urine culture
 Xray – skull / abdomen (iron poisoning)
 Lumbar puncture
 CXR
 CT scan
 DON’TS
 Don’t give the patient anything to drink or eat
 Don’t allow the patient to get up until he/she is fully

conscious
 Don’t crowd around the patient
 DO”S
 Pinch the patient to see if he/she can respond
 Examine the injuries and causes of unconsciousness
 Tilt the head back and keep the arms at right angle to body
 Raise the legs 8 – 12 inches, this promotes blood flow to the
brain
 Loosen any tight clothing
 Keep the victim warm if it is cold
 Keep record of casualty's condition
 Management/ outcome
 Treatment
◦ – Cause dependent.
 Prognosis is Influenced by:
◦ – Cause of coma
◦ – Coma duration
◦ – Intervention offered
◦ – Facilities available
 Outcome
◦ • Cognitive decline/ dementia/ mental retardation or dysfunction
◦ • Seizures
◦ • Behaviour disorder.
◦ • Paralysis.
◦ • Death.