Coma By Shireen Gupta

Definition Consciousness Coma State of awareness of self and the environment Coma Sleep-like state of unresponsiveness. No awareness of self or the environment

Alterations in Sensorium(seat of sensation) “Clouding of Consciousness” reduced wakefulness alternating with irritability; Defect in attention Delirium(acute confusional state) disorientation, fear, irritability altered perceptions of sensory stimuli rapid onset duration 5-7 days

Obtundation(less than full mental capacity) mild to moderate reduction in alertness mental blunting Stupor asleep or behaviorally unresponsive Aroused by repeated vigorous stimulation

Comatose state A person in a coma cannot be: awakened, fails to respond normally to pain, light or sound does not have sleep-wake cycles, and does not take voluntary actions.

Etiology intoxication metabolic abnormalities, Pyschogenic/CNS diseases Iatrogenic Structural lesion Medications

Anatomy of Coma Ascending Reticular Activating System (ARAS) Diencephalon Cerebral Cortex

ARAS Underlying cause: Damage to the Reticular formation of the hindbrain which is important in regulating sleep.

Diencephalon (Thalamus) Input from the ARAS Output to the cerebral cortex Bilateral injury required to produce coma

Cerebral Cortex Maintains awareness Bilateral diffuse cortical dysfunction can result in coma Focal lesion with mass effect Vegetative state

Ask GP, family and check medical records for this information HISTORY A llergies M edications P ast medical history L ast meal E vent Ask GP, family and check medical records for this information

Coma Examination Examination of the comatose patient is an examination of the brainstem In the initial assessment of coma, it is common to gauge the level of consciousness by response to vocal stimuli ("Can you hear me?") painful stimuli; this is known as the AVPU (alert, vocal stimuli, painful stimuli, unconscious) scale.  Glasgow coma scale quantify individual reactions such as eye opening, movement and verbal response on a scale.

The Glasgow coma scale Neurological scale - a reliable, objective way of recording the conscious state of a person, for initial as well as continuing assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and Generally, brain injury is classified as: Severe, with GCS ≤ 8 Moderate, GCS 9 - 12 Minor, GCS ≥ 13

Glascow Coma Score Eye opening Best verbal Best Motor spontaneous 4 voice 3 pain 2 nil 1 Best verbal oriented 5 confused 4 inappropriate 3 incomprehens. 2 Best Motor obeys 6 localizes 5 nl flexion 4 decorticate 3 decerebrate 2 nil 1

FOUR Score 4 components Eye responses E4 Motor responses M4 Brainstem reflexes B4 Respiration R4 CP1199945-54

Four Score Eye Response .

Motor Response

Brainstem Response

Respiration

Laboratory Electrolytes Calcium & magnesium CBC Toxicology/drug screen

Ancillary Studies Head imaging CXR ECG EEG

Emergent Therapies ABC’s D50 Narcan Thiamine Flumazenil

References Snells Neuroanatomy http://en.wikipedia.org