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  2. 2. What is coma? A coma ( from the Greek Koma, meaning deep sleep) is a profound state of unconsciousness, in which a person is unresponsive and unarousable. Reflex movements and posturing maybe present
  3. 3. Biology of consciousness Two components of conscious behavior  content- the sum of cognitive and affective function  arousal- appearance of wakefulness Content depends on arousal but normal arousal does not guarantee normal content
  5. 5. Epidemiology of Coma Plum and Posner  500 consecutive cases of coma  101 supratentorial (44/101 ICH)  65 subtentorial lesions (40/65 brainstem infarcts)  326 diffuse or metabolic brain dysfunction  149 drug intoxication
  6. 6. CAUSES According to etiology Traumatic Metabolic Vascular Infectious Toxic Structural Psychogenic
  7. 7.  Focal versus nonfocal. Focal: intracerebral hemorrhage, ischemic stroke, demyelinating diseases. Nonfocal: vascular, toxic, metabolic conditions, nutritional deficiencies, seizures, psychiatric conditions. Either: trauma, infections, tumors
  8. 8. DIAGNOSIS Medical History Physical Exam & Neurological Evaluation Eye Examination Laboratory Tests Imaging Studies EEG
  9. 9. Clues from History Onset of symptoms  sudden onset  fluctuations Associated neurologic symptoms Medications
  10. 10. Physical examination General examination. A thorough general examination, including vital signs, helps to establish and rule out potential causes of coma. Look for evidence of head trauma or metabolic encephalopathy.
  11. 11. Breathing . Cheyne-Stokes respiration: cerebral hemispheric or diencephalic injury or an encephalopathy (hypoxic or metabolic). Central hyperventilation: brainstem injury. Ataxic or Biot’s respiration, which can progress to apnea: injury to the reticular formation in the medulla and pons.
  12. 12. Eye examinationPupils (size, shape, position, PERLA)- Unilateral horner syndrome= hypothalamic lesion- Ipsilaterl pupil dilation= 3rd nerve palsy due to uncal herniation- Smaller than normal but reactive= metabolic encephalopathy- Fixed, dilated= overdose of atropine- Pinpoint, responsive= opiates
  13. 13. eye examination Corneal reflex Ciliospinal reflex Eye movements Oculocephalic/ calorics fundoscopy
  14. 14. Cranial Nerve Exam Cranial Nerve Exam  Pupillary light response (CN 2-3)  Occulocephalic/calorics (CN 3,4,6,8)  Corneal reflex (CN 5,7)  Gag refelx (CN 9,10)
  15. 15. Motor Exam Assess tone, presence of asterixis Response to painful stimuli  none  abnormal flexor  abnormal extensor  normal localization/withdrawal Reflexes
  16. 16. The Glasgow Coma ScaleEYE OPENING VERBAL RESPONSE MOTOR RESPONSESpontaneous 4 Oriented 5 Obeys command 6To speech 3 Confused 4 Localizes pain 5To pain 2 Inappropriate words 3 Withdraws 4None 1 Incomprehensible words 2 Abnormal flexor posturing 3 None 1 Abnormal extensor posturing 2
  17. 17. LABS Blood cp Blood glucose Serum eletrolytes Serum calcium ABGs Liver and renal function tests Toxicologic studies
  18. 18. Other investigations Imaging studies: CAT scan, MRI EEG, BCI LP
  19. 19. TREATMENT Recovery position
  20. 20. TREATMENT Appropriate treatment must be commenced concomitantly with routine measures Treat according to the cause The "Coma Cocktail" Its a mixture of thiamine 50mg , dextrose 50 % (25g) , and naloxene 0.4-1.2 mg given intravenously.
  21. 21. Other treatments Antibiotics Anticonvulsants Warm the pt if hypothermic Correct any electrolyte or metabolic imbalance Reduce raised ICP with diuretics or surgery Ventilation/ cardiovascular support
  22. 22. Long term treatment preventing infections such as pneumonia maintaining the patients physical state (preventing bed sores, for example) providing adequate nutrition.
  23. 23. PROGNOSIS The prognosis in comatose patients is typically poor except for those that are drug- related or result from traumas. In general, the longer the coma lasts, the poorer the prognosis. Coma rarely lasts longer than 4 weeks, after which, transition into a vegetative state or recovery occurs
  24. 24. THANK YOU