Medicine Approach and The Basic

1. General Approach And
Differential Diagnosis of Coma

3. OBJECTIVES
• Objective: Able to stabilize, evaluate, and
treat the comatose patient in the emergent
setting.
• To understand this involves an organized,
sequential, prioritized approach.

4. The Comatose Patient
Objectives
• Airway
• Breathing
• Circulation
• Treatment of rapidly progressive, dangerous
metabolic causes of coma (hypoglycemia)
• Evaluation as to whether there is significant
increased ICP or mass lesions.
• Treatment of ICP to temporize until surgical
intervention is possible.

5. Why Coma management
• Common medical emergency 3-5%
• Large proportion of comatose patient
recover
• Untreated coma may lead to further brain
damage

6. Is it Coma ?
Coma is prolonged Unconsciousness Or
Unarousible Unresponsiveness.
Quantify using the Glasgow coma
scale.

7. Causes/Differential Diagnosis of
Coma
• Traumatic - head injury
• Vascular - Cerebral thrombosis
Cerebral Haemorrhage (ICH/SAH)
Hypertensive encephalopathy
• Meningitis,encephalitis,brain abscess,cerebral malaria
• Brain tumor & other SOL
• Epilepsy & postictal states
• Psychiatric problems (Hysteria,depression,catatonia)
• Organ failure - hepatic coma,respiratory coma,uraemic
coma

8. • Metabolic
 Hyperglycemia , hypoglycemia
 Hypernatraemia , hyponatracemia
 Hyperthermia , hypothermia
 Hypercalcaemia , Water intoxication (SIADH)
 Diabetic coma
 Myxodemic coma
• Endogenous
 Intoxication / drugs - sedative,morphine,pethidine
 Alcohol intoxication : alcohol withdrawl $

9. Consciousness
• Perception
• Reaction
• Wakefulness

10. Level of
consciousness
Spontaneous 4
To Speech 3
To Pain 2
Absent 1
Converses/Oriented 5
Converses/Desoriented 4
Inapropriate 3
Incomprehensible 2
Absent 1
Obeys 6
Localizes Pain 5
Withdraws(flexion) 4
Decorticate(flexion)
Rigidity
3
Decerebrate(extension)
Rigidity
2
Absent 1
Eyes Open
Verbal
Motor
The sum obtained in this scale is used to the assess
Coma and Impaired consciousness
Mild is 13 through 15 points
Moderate is 9 to 12 points
Severe 3 through 8 points
Patients with score less than 8 are in Coma
GCS

11. Coma - Aetiology
Metabolic:-
– Ischemic hypoxic
– Hypoglycaemic
– Organ failure
– Electrolyte disturbance
– Toxic
Structural:-
– Supratentorial bilateral
– Unilateral large lesion
with transtentorial
herniation
– Infratentorial

12. Metabolic encephalopathy
• Confusional state -> coma , fluctuation
• No focal neurological sign
• No neck stiffness
• Normal brainstem reflexes
• Coarse tremor
• Multifocal myoclonus
• Asterixis
• Generalized/periodic myoclonus

13. History
• Circumstances and temporal profile
• Of the onset of coma
• Details of preceding neurological symptoms
headache, weakness and seizure
• Any head injury
• Use of drug (e.g. Steroid) and alcohol
• Previous medical illness liver, kidney
• Previous psychiatric illness

14. Examination
• General physical examination
• Evidence of external injury
• Colour of skin and mucosa
• Odour of breath
• Evidence of systemic illness
• Heart and lung

15. Neurological examination
• Fundoscopy
• Pupil size and response to light
• Ocular movements
• Posture and limb movement
• Reflexes

16. Cushing Triad
Kocher-Cushing response - rise in BP-
>bradycardia due to rise in ICP ->
compression of floor of the 4th ventricle
Stimulation to respiratory center- increase
respiratory rate
fall in BP and tachycardia usually terminal
event due to medullary failure

17. Pupil
• Diencephalic (metabolic) Small reactive
• Midbrain tectal Midsize,fixed
• Midbrain nuclear Irregular pear
shaped
• 3rd nerve Fixed widely dilated
• Pontine haemorrhage Pinpoint reactive
 Opiate Pinpoint
• Organophosphorus Small
• Atropine Wide dilated

18. Motor Exam Key Points:
• Assess tone, presence of asterixis
• Response to painful stimuli
– none
– abnormal flexor
– abnormal extensor
– normal localization/withdrawal
• Symmetric responses seen with metabolic or
structural causes
• Asymmetric responses seen with structural causes

19. Posture
• Cerebral hemisphere
– Decorticate posture
• Diencephalon supratentorial
– Diagonal posture
• Upper brain stem
– Decerebrate posture
• Pontine
– Abnormal ext arm
– Weak flexion leg
• Medullary
– Flaccidity

20. Investigation
• Complete blood count, MP, B.sugar
• Blood urea, s. creatinine,
s.electrolyte
• Blood gases, ALT, AST
• CSF examination
• CT scan/ MRI
• X-ray chest, ECG

21. Management
• Check vital signs - BP,HR,RR
 Patent airway
 Adequate breathing
 Adequate circulation
• Correct the reversible cause
Rapid history taking & rapid and through P.E
 50% glucose
 Nalosone, Nalophine (Narcotic overdose)
 Vit B1 for Wernicke’s encephalopathy
 Flumazenil if coma due to diazepam overdose
• GCS assessment

22. Treatment
1. Turn the patient frequently to prevent aspiration,sore,hypostasis
– Skin care
– Bladder care
– Bowel care
Continue treatment
2. If the General condition stablilized, do CT head scan to detect
organic lesion
– Infract can’t be seen immediately,can see at least 6-8 hr
– Haemorrhage can be seen immediately-do CT scan
immediately
– Tumour-can see as SOL

23. 3. CT head - Normal -do LP
– If infection present - treat
4. CT & LP - normal - treat metabolic (if consider metabolic)
– If deteriorate ,consider expansion of disease, new lesion and metabolic
5. Increased ICP - osmotic diuresis
– Mannitol - 20% in 200cc N/S within 20min.
6. Evaculation of Haemorrhage - refer to neurosurgery
7. Infract - symptomatic treatment
• Prognosis
– Can be determined by GCS & Head injury
– If there is no improvement within 48 hr, prognosis is bad.