1. Coma
By Shireen Gupta

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

3. 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

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

5. 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.

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

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

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

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

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

11. 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

12. 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.

13. 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
Minor, GCS ≥ 13

14. 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

15. FOUR Score 4 components Eye responses E4 Motor responses M4
Brainstem reflexes B4
Respiration R4 CP

16. Four Score Eye Response.

17. Motor Response

18. Brainstem Response

19. Respiration

20. Laboratory
Electrolytes
Calcium & magnesium
CBC
Toxicology/drug screen

21. Ancillary Studies
Head imaging
CXR
ECG
EEG

22. Emergent Therapies
ABC’s
D50
Narcan
Thiamine
Flumazenil

23. References
Snells Neuroanatomy