Common Causes I Interruption of energy substrate delivery a.Hypoxia b.Ischemia c.Hypoglycemia Alteration of neurophysiologic responses of neuronal membranes a.Drug intoxication b.Alcohol intoxication c.Epilepsy
Common Causes II Abnormalities of osmolarity a.Diabetic ketoacidosis b.Nonketotic hyperosmolar state c.Hyponatremia Hepatic encephalopathy Hypertensive encephalopathy Uremic encephalopathy
Common Causes III Hypercapnia Hypothyroidism Hypothermia Hyperthermia
An unconscious case 46 years old, male DM Unconscious
Disability - D Disability is determined from the patient level of consciousness according to the AVPU or GCS. A for ALERT V for VOICE P for PAIN U for UNRESPONSIVE to any stimulus
GLASGOW COMA SCALE I. Motor Response 6 - Obeys commands fully 5 - Localizes to noxious stimuli 4 - Withdraws from noxious stimuli 3 - Abnormal flexion, i.e. decorticate posturing 2 - Extensor response, i.e. decerebrate posturing 1 - No response II. Verbal Response 5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and jumbled phrases consisting of words 2 - Incomprehensible sounds 1 - No sounds III. Eye Opening 4 - Spontaneous eye opening 3 - Eyes open to speech 2 - Eyes open to pain 1 - No eye opening
Exposure an Environment - E The patients clothes should be removed or cut in an appropriate manner so that any injuries can be seen.
General Physical Examination History Neurologic examination The eye examination Fundoscopy Ventilatory pattern
History In many cases, the cause of coma is immediately evident; -Trauma -Cardiac arrest -Drug ingestion In the reminder, historical information may be helpful..
Evolution of neurologic signs in coma from a hemispheric mass lesion as the brain becomes functionally impaired in a rostral caudal manner. Early and late diencephalic levels are levels of dysfunction just above (early) and just below (late) the thalamus.
The eye examination Pupillary abnormality is one of the cardinal features differentiating surgical disorders from medical disorders. Pupillary abnormalities in coma generally herald structural changes in brain, whereas in metabolic coma such abnormalities are not present.
Laboratory examination Chemical blood determinations are made routinely to investigate metabolic, toxic or drug induced encephalopaties. -Electrolytes -Calcium -Blood urea nitrogen -Glucose -NH 3
Laboratory examination Toxicological analysis is of great value in any case of coma where the diagnosis is not immediately clear. The presence of alcohol does not ensure that alcohol is the cause of the altered mental status. Other, life-threatening, causes must be ruled out.The presence of alcohol does not ensure that alcohol is the cause of the altered mental status. Other, life-threatening, causes must be ruled out.
Imaging In coma of unknown etiology, CT or MRI must be performed. Radiologically detectable causes of coma; -Hemorrhage -Tumor -Hydrocephalus
Electroencephalography EEG is useful in unrecognized seizures.
Lumbar puncture The use of LP in coma is limited to diagnoses of meningitis and instances of suspected subarachnoid hemorrhage in which the CT is normal.
Complaints Diagnosis Action History of diabetes, use of oral anti-diabetic or ingestion of alcohol * Hypoglycaemia *Test blood for glucose using test strip or glucose meter. Give IV Glucose History of ingestion of medication (tablets or liquid). There may be smell of alcohol or other substance on breath Drug overdose. e.g. Alcohol, Support respiration IV Glucose to prevent hypoglycaemia. In chronic alcoholics Precede IV glucose with IV Thiamine, IV fluid administration. E.g. Paracetamol. Gastric lavage, n- acetylcysteine treatment if > 140 mg/kg body weight ingested
ComplaintsDiagnosisAction Presence or absence of history of diabetes; - polyuria, polydipsia - hyperventilation - gradual onset of illness - evidence of infection - Urine sugar and ketone positive - Blood glucose> 250 mg/dL * Diabetic ketoacidosis *Give Soluble Insulin and Sodium Chloride 0.9% infusion Fever, fits, headache, neck stiffness, altered consciousness etc * Meningitis or Cerebral Malaria *Treat with antibiotics and quinine until either diagnosis confirmed. History of previous fits, sudden onset of convulsions; with or without incontinence. * Epilepsy *Give Diazepam, IV, to abort fits and continue or start with anti-epileptic drug treatment
Patient with hypertension or diabetes; sudden onset of paralysis of one side of body. * Stroke Check blood pressure and blood glucose. Patient with hypertension, headaches, seizures * Hypertensive encephalopathy Check blood pressure If very high, give oral or parenteral anti-hypertensives ComplaintsDiagnosisAction