Transcript COMA

Definition of consciousness : refers to a state of
cerebral arousal which allows the brain to
executes it’s functions of sensory perception of
data input to him from the 5 common senses.
The principal causes of coma are: 
(1) lesions that damage the reticular activating
system in the upper pons or its projections
(2) destruction of large portions of both 
cerebral hemispheres.
(3) suppression of reticulocerebral function by
drugs, toxins, or metabolic derangements such
as hypoglycemia, anoxia, uremia, and hepatic
failure
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

-Coma : defined as a deep sleeplike state from
which the patient cannot be aroused.
-Stupor : refers to a higher degree of 
arousability in which the patient can be
transiently awakened only by vigorous
stimuli.
-Drowsiness : which is familiar to all persons,
simulates light sleep and is characterized by
easy arousal and the persistence of alertness for
brief periods


-Vegetative state : signifies an awake but
nonresponsive state in a patient who has emerged
from coma. In the vegetative state, the eyelids may
open, giving the appearance of wakefulness.
Respiratory and autonomic functions are retained.
Yawning, coughing, swallowing, as well as limb
and head movements persist and the patient may
follow visually presented objects , it indicate
bilateral cerebral hemispheric lesion , if this state
persist for more than 1 year then described as
persistent vegetative state which carries a very
poor prognosis.
-Confusion , a mental and behavioral state of
reduced comprehension, coherence, and
capacity to reason.
-Delirium , a term used to describe an acute
confusional state, with agitation and autonomic
disturbances with visual hallucination .
Causes of confusion and coma
A-diseases that not cause focal or lateralizing sign
1-intoxication like alcohol, sedative drugs ,opiates
2-metabolic causes like : uremia , liver failure ,
hyponatremia , hypernatrmia, hypoglycemia ,
brain anoxia ,diabetic ketoacidosis , non ketotic
hyperosmolar coma , hypo and hyperthyroid ,
Addison disease
3- sever systemic infection like : pneumonia , typhoid
fever , septicemia
4- postictal state , status epilepticus , non convulsive
status
5- shock from any cause
6- hypertensive encephalopathy , eclampsia
7- sever hypothermia and hyperthermia
8- concussion
9- acute hydrocephalus
B- diseases with meningial irritation with or
without fever
1-acute bacterial meningitis
2-viral encephalitis
3-TB meningitis
4-subarachnoid hemorrhage
5-carcinomatuos meningitis
C-diseases that cause focal or lateralizing sign
1-intracerebral hemorrhage
2-cerebral infarction
3-brian abscess
5-epidural and subdural hemorrhage
6-brain tumor
7-wide spread brain injury
8-acute disseminated encephalomyelitis
9-cerebral venous thrombosis
10- pituitary apoplexy
Aproach Of Patient With Coma Or Confusion
HISTORY In many cases, the cause of coma is
immediately evident (e.g., trauma, cardiac
arrest, or reported drug ingestion). In the
remainder, certain points are especially useful:
(1) the antecedent symptoms (confusion,
weakness, headache, fever, seizures, dizziness,
double vision, or vomiting).
(2) the use of medications, illicit drugs, or alcohol.
(3) chronic liver, kidney, lung, heart, or other
medical disease
General and systemic examination look for :
-Jaundice , anemia , cyanosis, purpura
-Check vital signs for pulse , temp. , resp. rate ,
B.P ,
-Check lung , abdomen , abdomen for any
systemic abnormality
-Look for signs of head trauma (racoon eye
indicate anterior cranial fossa fracture ,battle
sign indicate middle or posterior fossa fracture
).
Neurological assessment for the followings:
1-conciousness level : confused , drowsy , stuporus
,comatos.
2-pupile for size, shape ,reaction to light, if there is
miosis , midriasis , anisochoria (unequal size
pupil).
Pupillary Sings
1-unilat. Dilated pupil mean 3rd. nerve lesion from
uncal herniation.
2-bilat. Small size pupil reacting to light means bilat.
Deep cerebral lesion or thalamic lesion or
metabolic cause.
3- bilat.pinpoint pupil indicate pontine lesion or
opiate toxicity
4-bilat. Dilated pupil indicate midbrain lesion.
3-ocular motility by dolls eye maneuver to detect
midbrain or pontine lesion.
4-brainstem reflexes : corneal reflex , gag reflex.
5- meningial signs.
6- examine for any focality or lateralization by
applying painful stimulus if there is paralysis
of one side.
7-check for planter response if there is unilat.
Extensor planter or bilat.
8-check for respiratory pattern if there is
apneustic breathing ,ataxic breathing ,
chennystok breathing.
9-examine for abnormal posture decerbrate or
decorticate.
10- fundoscopic examination for papilloedema.
11-looking for any abnormal movement like focal
or generalized seizure or myoclouns.
12- look for any eye deviation to one side (gaze
preference or palsy) .
LABORATORY STUDIES AND IMAGING
1-Random blood sugar
2-Renal function test
3-liver function test
4-serum electrolyte
5-thyroid function test
6 -complet blood count
7-serum cortisol level
8- arterial blood gas analysis
9- urgent ct scan of brain looking for hemorrhage ,
srtoke,mass lesion
10- chest x ray
11-MRI if CT brain does not reveal specific insult
also looking for demyelination, MRV to detect
cerebral venous thrombosis.
12- lumbar puncture if there is meningeal signs or
if CNS infection suspected this is done after
exclusion of mass lesion by brain ct.
13-EEG if there is focal or generalized fit or there
is loss of consciousness without obvious cause
to exclude non convulsive status epilepticus
13- toxicology screen for drugs and alcohol
Treatment
1-ABC patent airway if airway occluded put tube
even mechanical ventilator if needed, oxygen ,
canula for drawing blood for full biochemical,
toxicological and hematological assay and for
circulatory support.
2-thiamin 100mg i.v then glucose hyprtonic i.v if
alcoholic intoxication suspected or if there is
hidden cause of coma .
3-naloxone i.v if opiate toxicity suspected or if there is
hidden cause for coma.
4- NG tube for feeding and for oral drugs.
5-If there is seizure start antiepleptics or if there is
status epilpticus manage it accordingly.
6- treat underlying cause like correct metabolic ,
toxicological causes if identified or treat the
structural cause if present accordingly like
stroke, hemorrhage , meningitis….etc.
7- if intracranial pressure high start to decrease it
by manitol ,hypertonic saline , hyperventilation
using mechanicalventilator and by
hypothermia.