COMA

DIAH MUSTIKA HW,SpS,KIC

INTENSIVE CARE UNIT of EMERGENCY DEPARTMENT

NAVAL HOSPITAL dr RAMELAN, SURABAYA

DEFINITIONS

Coma

• State of unresponsiveness to external or internal stimuli in which a patient lies w/ eyes closed unaware of the environment

Consciousness

• State of awareness of both the self and the environment

• ARAS : rostral pons, midbrain, thalamus, hypothalamus

• Wakefullness or alertness Arousal

• Cerebral cortex and connection to subcortical white matter

• Attention, memory,motivation and executive function

Content

Alert : fully consciousAAlert: Fully conscious Lethargic: appear somnolent, but may be able to maintain

arousal spontaneously or with repeated light stimulation Obtunded: requires touch or voice to maintain arousal Stuporous: unresponsiveness from which the individual can

be aroused only by vigorous and repeated stimulus Comatose: state of unarousable unresponsiveness in which

individual lies with eyes closed, lacking awareness of self and environment

Levels of Arousal:

Motor

Response Example Score

Commands Follows simple commands 6

Localizes

Pain

Pulls examiner's hand away

when pinched 5

Withdraws

from Pain

Pulls a part of body away when

pinched 4

Abnormal

Flexion

Flexes body inappropriately to

pain 3

Abnormal

Extension

Body becomes rigid in an

extended position when

examiner pinches him 2

No Response Has no motor response to pinch 1

Eye-Opening .

Spontaneous Opens eyes on own 4

To Voice

Opens eyes when asked to

in a loud voice 3

To Pain Opens eyes when pinched 2

No Response Does not open eyes 1

Verbal Response

(Talking) .

Orientated

Carries on a conversation

correctly and tells examiner

where he is, who he is, and

the month and year 5

Confused

Conversation

Seems confused or

disoriented 4

Inappropriate Words

Talks so examiner can

understand him but makes

no sense 3

Sounds

Makes sounds that

examiner cannot understand 2

No Response Makes no noise 1

EMERGENT MANAGEMENT

Stabilization:

• Airway – Assess for patency

– Assess for ability to protect

• Breathing – Assess ventilation

– Assess breathing pattern

• Circulation – Assess measures of cardiac output

• Hyper or hypothermia should reversed appropriately to normothermia

Evaluation:

• History

• Physical Exam

• Laboratory and Imaging Studies

Evaluation—History:

• Rapid initial history: – Recent history prior to mental status changes

– Past medical history (seizures)

– Family history (specifically seizures/neurologic disorders)

– Trauma ?

– Febrile ? / Other signs or symptoms of infection

– Diet

– Exposure to drugs/toxins

• Follow-up with more complete history:

Evaluation—Physical Exam:

• Systemic

– Vital Signs

– Signs of trauma

– Signs of infection

– Signs of bleeding

– Signs of other systemic illnesses

Evaluation—Physical Exam:

• Rapid Neurologic Exam:

– Pupils

– Respiratory pattern

– Stimuli needed to elicit response

– Character of the response

Neurologic Exam—Pupils:

Respiratory patterns:

Cheyne-Stokes

Central

Hyperventilation

Apneustic

Cluster

breathing/Gasping

Agonal breathing

Hemispheric

Midbrain

Mid/Lower Pons

Low Pons/Upper

Medulla

Medulla

Location Pattern

Posturing:

Decorticate

lesion above

midbrain

Decerebrate

lesion below

midbrain

Common etiologies of coma Structural Lesions

Supratentorial

Generalized/bilateral

Infectious/positinfectious

Encephalitis

Acute disseminated encephalomyelitis

Vascular

Anoxic – ischmenic encephalopathy

Multiple cortical infarctions

Bilateral thalamic infarctions

Traumatic

Diffuse axonal injury

Penetrating brain injury

Multiple contusions

Neoplastic

Glimatosis

Leukoencephalopathy

Multiple brain metastases

Lymphoma

Focal (with mass effect)

Intraparenchymal hematoma

Large stroke with edema

Abscess

Tumor

Infratentorial

Brain stem

Pontine hemorrhage

Basilar artery thrombis

Central pontine myelinolysis

Cerebellum

Infraction with edema

Hematoma

Abscess

Tumor

Metabolic derangements

Hypoglycemia

Hyperglycemia (nonketotic hyperosmolar)

Hyponatremia

Hypercalcemia

Panhypopituitarism

Hyperbilirubinemia

Acute uremia

Diffuse Physiologic Brain Dysfunction

Status epilepticus

Poisoning

Drug overdose

Gas inhalation

Hypotthermia

Basiliar migraine

Malignant neuroleptic syndrome

Hypoxia

Psychogenic Unresponsiveness

Catatonia

Conversion disorder

Malingering

Adapted from Ziai WC. Coma and altered consciousness. In Bhardwaj A, Mirski

MS, Ulatowski JA (eds), Current Clinical Neurology : Handbook of Neurocritical

Care. Totowa, NJ : Humana Press, 2004, pp 1 – 18

Thanks for your attention