Coma

Chapter: Coma
McMaster Section Editor(s): Akbar A. Panju
Section Editor(s) in Interna Szczeklika: Miłosz Jankowski
McMaster Author(s): Serena Gundy, Jason Cheung, Mohamed Panju, Ameen Patel
Author(s) in Interna Szczeklika: Miłosz Jankowski, Konstanty Szułdrzyński, Grażyna Zwolińska
Additional Information

Coma is a prolonged loss of consciousness with a reduced response to external stimuli.

Causes: Table. Table 1. Typical manifestations of….

ManagementTop

1. Assess the patient using the approach outlined in the basic management of initial loss of consciousness.

2. Assess consciousness (depth of coma): Check responsiveness (to voice, touch, and pain) using the Glasgow Coma Scale (GCS) ([Table 1 in Consciousness]). Reevaluate the GCS often to monitor for any fluctuation in the patient’s mental status.

3. Perform a complete head-to-toe assessment:

1) Vitals: Tachycardia, bradycardia, hyperthermia, hypothermia, hyperventilation, hypoventilation.

2) Eyes: Pupil size and reactivity, nystagmus, gaze deviation, scleral icterus; fundoscopy for papilledema.

3) Head and neck: Meningismus, tongue biting, Battle sign.

4) Neurologic examination: Ability to follow commands, tone, deep tendon reflexes, Babinski reflex, asterixis, posturing (decerebrate/extensor or decorticate/flexor), convulsions, myoclonus.

5) Cardiovascular examination: Murmurs, arrhythmias, volume status.

6) Respiratory examination: Pattern of breathing (Cheyne-Stokes, Kussmaul), decreased breath sounds, wheezes, crackles.

7) Abdominal examination: Distension, ascites, peritoneal signs, distended bladder.

8) Dermatologic examination: Cellulitis, sacral or heel ulceration, signs of intravenous drug use.

4. Initiate universal and, as applicable, specific antidotes:

1) Thiamine 100 mg IM or IV (administer before glucose [dextrose]).

2) Glucose (1 ampoule of 50% dextrose in water).

3) Naloxone 0.4 mg IV (if opioid overdose is suspected).

4) Supplemental oxygen (100% FiO2 if carbon monoxide poisoning is suspected).

5. Order diagnostic tests:

1) Electrocardiography (ECG).

2) Laboratory tests:

a) Complete blood count: An elevated white blood cell count may indicate a central nervous system infection.

b) Serum biochemistry tests: Serum levels glucose (low or elevated in hyperosmolar hyperglycemic nonketotic coma and diabetic ketoacidosis), sodium, potassium, ammonia (usually elevated in hepatic coma), urea/blood urea nitrogen (BUN) and creatinine (elevated in uremia), lactate (elevated in hypoxia and shock), calcium (elevated in hypercalcemic crisis).

c) Arterial blood gases results may reveal hypercapnia, hypoxemia, and acidosis.

d) Serum and urine osmolality (elevated in toxic alcohol ingestions).

e) Toxicology screen if ingestion suspected.

f) Acetylsalicylic acid and paracetamol (INN acetaminophen) levels (in all patients with suspected overdose, as ingestion is common)

g) Thyroid-stimulating hormone levels (high in myxedema coma).

h) Urinalysis: Elevated ketone bodies (and sometimes glucose) in ketoacidosis.

i) Lumbar puncture and cerebrospinal fluid examination if meningitis or encephalitis are suspected.

3) Imaging studiesComputed tomography (CT) of the head with no contrast enhancement allows visualization of intracranial bleeding and cerebral edema. Chest radiographs are used to assess for atelectasis due to aspiration (perform a therapeutic bronchoscopy if necessary).

6. Carry out a differential diagnosis of coma (Table. Table 1. Typical manifestations of…), determine the cause, and treat the underlying condition, if possible.

TablesTop

Table. Table 1. Typical manifestations of coma based on etiology

Etiology

Causes

Typical manifestations

Vascular

Subarachnoid or intracranial hemorrhage

Sudden onset, headache, vomiting, focal neurologic signs, signs suggestive of meningitis

Extensive stroke affecting bilateral cerebral hemispheres or brainstem

Sudden onset, focal neurologic signs, progressive clinical deterioration

Trauma

Direct brain injury or accumulating subdural hematoma

History of trauma, lacerations or other signs of head trauma, bleeding from ears or cerebrospinal fluid leakage from the nose or ears

Increased intracranial pressure

Brain tumor or abscess, subdural hematoma

History of an escalating headache, progressive impairment of mental status, papilledema, focal neurologic signs

Inflammatory

Meningitis

History of headache and fever, subacute course, signs suggestive of meningitis

Encephalitis

As above plus signs of disseminated encephalopathy, seizures, involuntary movements

Metabolic

Hypoglycemia

Hyperhidrosis, dilated pupils, seizures, hyporeflexia, Babinski sign, sometimes focal neurologic signs

Hyperglycemia

Hyperventilation, Kussmaul breathing

Uremia

Progressive apathy, progressive obtundation, tremor, seizures

Liver disease

Coma is preceded by memory impairment, confusion, and somnolence with subsequent development of pyramidal, extrapyramidal, and cerebellar signs and low frequency tremor

Hypercalcemia

Signs of hypercalcemia

Hyponatremia

Cerebral edema caused by changes in the cerebrospinal fluid and cell tonicity, can also be provoked by overly rapid correction in a patient with chronic derangement

Hypernatremia

Signs of hypernatremia

Myxedema

History of hypothyroidism, gradual deterioration over weeks, common hypercapnia

Epilepsy

Epilepsy

Sudden abnormalities of behavior or mental status, seizures, sometimes extremity paresis

Hypoxia

Cardiac and respiratory arrest

Sudden onset, decortication or decerebration, myoclonus, epileptic seizures

Hypercapnia

Carbon dioxide retention in patients with respiratory insufficiency

Gradual deterioration of mental status, prior headache, shallow respiration, conjunctival injection

Extreme body temperatures

Hypothermia

Signs of hypothermia

Hyperthermia

Signs of hyperthermia

Toxins

Toxic alcohols, ethanol

Signs of alcohol intoxication

Anticholinergics, sedative hypnotics, antipsychotics, opioids, carbon monoxide poisoning

Signs of poisoning and intoxication

Psychiatric

Catatonia

Pseudocoma

History of psychiatric diagnosis and deterioration, normal cold caloric testing

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