Coma Coma is a state in which the patient is unresponsive to environmental stimuli, unable to communicate in any manner and from which he or she cannot be aroused. The examination requires a special approach because the patient cannot give a history and

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COMA
State of unarousable unresponsiveness to all
external stimuli called coma sleeplike state
from which the patient cannot be aroused
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• Stupor
• it is a state from which the subject only be
  aroused by vigorous and continuous stimulation
• Drowsiness
• which is the familiar to all persons,
  simulates light sleep and is characterized by
  easy arousal and the persistence of alertness for
  brief periods.
• Drowsiness and stupor are associated with some
  degree of confusion.

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• Vegetative state
• It signifies an awake but unresponsive state.
  These patients have emerged from coma after
  period of days or weeks to an unresponsive state
  in which the eyelids are open, giving the
  appearance of wakefulness.
• Yawning, coughing, swallowing, as well as
  limb and head movements persist.

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Normal Physiology of Consciousness

• Consciousness is maintained by the normal
  functioning of the brain stem reticular
  activating system and it's bilateral projections
  to the thalamus and cerebral hemispheres.

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Causes of Coma

• Metabolic
• Diabetes Mallitus
• Hypoglycemia
• Hypocalemia
• Hypocalcemia
• Hypercalcemia
• Hyponatremia
• Hypothyroidism
• Hyperadrenalism
• Hepatic Failure
• Renal FailureHypercarbiaThiamine Deficiency
• Drug Physical agents
• Alcohol ingestion
• Anaesthetic agents
• Drug overdose
• Hypothermia

Brain stem lesions hemorrhage Abscess
Meningitis Encephalitis Tumor Trauma
Cerebellar Infarction Cerebral hemisphere
lesion with sec compression of the Brain stem
hemorrhage Meningitis Encephalitis Tumor
Trauma Cerebral malaria Infarction
Epilepsy Hydrocephalus Hypertensive
encephalopathy
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• Emergency Management
• The approach to diagnosis of the comatose patient
  consists of two steps
• First you need to stabilize the patient and treat
  presumptively life-threatening disorders.
• After that, efforts are directed to establish an
  etiologic diagnosis

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• History
• After the emergency measures have been taken with
  successful, you will need to obtain a description
  of onset of coma and a history of any chronic
  illness,
• eg, diabetes, hypertension or drug abuse.
• Time factor is imp to guide your clinical
  investigation.
• For example a sudden onset of coma suggest a
  vascular origin and in contrast a more protracted
  course is seen with tumor, Abscess or chronic
  subdural hematoma

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• General Physical Examination

• General Physical Examination of comatose patient
  should include
• Level severaty of coma
• Lateralised focal deficits ( hemiparesis,facial
  weakness,etc)
• Pupillary size response
• Pattern of motor response respiration
• Occulocephalic reflex
• Complete systemic examination

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General Physical Examination
. respiratory movements- Deep rapid breathing-
Diabetic coma, Aspirin poisoning Shallow Slow
Breathing-Morphine, Barbiturate,
hypoglycemia Cheyne-Stokes breathing-
Cerebral hemorrhage, Uremia Kussmaul
breathing-Ketoacedosis, Uremia, Resp. failure
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• Blood Pressure
• Elevation of blood pressure can indicate
• 1. Long-standing hypertension, which
  predisposes to intracerebral hemorrhage or
  stroke).2. Hypertensive Encephalopathy3. May
  be a consequence of the process causing the coma
  ( intracerebral or subarachnoid hemorrhage
• -----Lead poisoning uremia
• Hypotension-
• Hypoglycemia
• D.M.
• Addisons disease

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• Temperature
• 1. Hypothermia
• ethanol or sedative drug intoxication,
• Wernicke's encephalopathy,
• hepatic encephalopathy,
• Myxedema.2. Hyperthermia
• status epilepticus,
• pontine hemorrhage, heat stroke,
• malignant hyperthermia anticholinergic
  intoxication.

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• Color
• Look for
• Icterus- Hepatic coma
• cherry-red color - carbon monoxide poisoning
• cyanosis methemoglobinemia.
• Facial muscles
• for asymmetry of the face which may indicate
  hemiplegia
• Puffy face- Uremic coma

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• Oral Cavity
• Look for lacerations in the tongue which may
  indicate biting during a convulsive seizure.
• Smell the breath for
• alcohol alcohol intoxication
• Urinous odour- Uremia
• Rotten fruit( acetone)- Diabetic coma
• Foster hepaticus( mousy odour)-Hepatic coma

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• Ears
• Look for pus-
• meningitis
• Neck
• Test for nuchal rigidity, Brudzinski sign,
  Kernig sign, for evidence of meningeal irritation.

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• Optic Fundi
• Papilledema or retinal hemorrhage which may
  indicate chronic or acute hypertension or an
  elevation in intracranial pressure.
  hemorrhages in an adult suggest subarachnoid
  hemorrhage.

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• Signs of trauma
• Battle's sign ( swelling and discoloration
  overlying the mastoid bone behind the ear)
• e.g. Tempo. Skull
• Raccoon eyes (Periorbital ecchymosis)Cerebrospin
  al fluid rhinorrhea or otorrheaSkull fractures

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• Neurologic Examination
• The neurologic examination is very important
  to etiological diagnosis and have to be done with
  special attention.The results have to be recorded
  because they will help later in evaluating the
  treatment.

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Pupils - Pupillary size(normal 3-4 mm in
diameter) and reactivity is dependent on
sympathetic parasympathetic innervation. Brain
stem reflexes, such as the pupillary reaction to
light, offer clues to the location of the lesion
responsible for the coma.
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• Bilateral dilated pupils
• are greater than 7 mm in diameter and do not
  react to light stimulation. Are seen in
• a. Transtentorial herniation of both medial
  temporal lobes
• b. Anticholinergic or Sympathomimetic drug
  intoxication
• e.g. Atropin poisoning

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• Bilateral pinpoint pupils
• Have 1-1.5 mm in diameter and are seen in
• a. Morphine poisoning b. Pontine
  hemorrhage c. neurosyphilis d.
  Organophosphates poisoning e. Miotic eyes drops

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• Asymmetric pupils(anisocoria)
• With a difference of 1 mm or less in diameter
  and a normal constriction response to light.
• If the dilated pupil do not react to light or
  do it slowly, it usually indicates a rapidly
  expanding lesion on the ipsilateral side as in
  subdural or middle meningeal hemorrhage or brain
  tumor, that is compressing the midbrain or
  oculomotor nerve directly or by mass effect.

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• Fixed midsized pupils
• Are about 5 mm in diameter,
• do not react to light
• are the result of midbrain lesion.
• e.g. Brain stem death

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• Extraocular Movements
• In the comatose patient eye movements are tested
  by stimulating the vestibular system by the
• oculocephalic reflex (doll's head maneuver) which
  consists of passive head rotation or
• oculovestibular reflex (cold-water calorics test)
  which uses ice-water irrigation against the
  tympanic membrane.

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Doll's head maneuver
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• Normal
• The presence of full reflex eye movements( full
  conjugate horizontal eye movement during the
  doll's head maneuver
• and tonic conjugate movement of both eyes to
  the side of the ice-water irrigation during
  caloric test) attests to the integrity of the
  brain stem from the pontine to the midbrain
  level.
• -Abnormal a. Impaired unilateral adduction
• oculomotor nerve or midbrain lesions involving
  the oculomotor nucleus.
• b. Downward deviation of one or both eyes - is
  suggestive of sedative drug
  intoxication.
• c. No response
• a structural lesion of the brain stem at the
  level of the pons or a metabolic disorder with a
  particular predilection for brain stem
  involvement(sedative drug intoxication).

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• THANK YOU

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• Stupor t refers to lesser degrees of
  unarousability in which the patients can be
  awakened only by vigorous stimuli, accompanied by
  motor behavior that leads to avoidance of
  uncomfortable of aggravating stimuli.
• Drowsiness which is the familiar to all
  persons, simulates light sleep and is
  characterized by easy arousal and the
  persistence of alertness for brief periods.
  Drowsiness and stupor are associated with some
  degree of confusion.
• Vegetative state It signifies an awake but
  unresponsive state. These patients have emerged
  from coma after period of days of weeks to an
  unresponsive state in which the eyelids are open,
  giving the appearance of wakefulness. Yawning,
  coughing, swallowing, as well as limb and head
  movements persist.
• Akinetic mutism partially or fully awake
  patient who is able to form impressions and think
  but remains immobile and mute, particularly when
  unstimulated.
• Abulia It is mental and physical slowness and
  diminished ability to initiate activity that is
  in essence a mild form of akinetic mutism with
  same anatomic origins.
• Catatonia It is curios hypo mobile and mute
  syndrome associated major psychosis . Patient
  appears awake with eyes open but make no
  voluntary of responsive movement although they
  blink spontaneously, swallow and may appear
  distressed. Eyes are half open if patient is in
  fog or light sleep.
• Examination eyelid elevation is
  actively resisted
• -
  blinking occurs in response to visual threat
• - eyes
  moves concomitantly with head rotation
• Locked in state it describes as psedocoma in
  which awake patient has no means of producing
  speech of volitional movement in order to
  indicate that he is awake but vertical eye
  movement and lid elevation remains unimpaired,
  thus allowing the patient to signal.