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  1. 1. COMA Coma is classically defined as loss of mobility, sensation and consciousness with preservation of autonomic functions. Coma is caused by dysfunction of either or both the reticular activating system and cerebral cortex. The most common cause of coma are toxic metabolic de-arrangement, which are potentially treatable and reverersible. The big three are toxic/metabolic causes,trauma and stroke. CAUSES 1. Brain cancer 2. Concussion 3. Diabetes 4. Drug abuse 5. Encephalitis 6. Kidney failure 7. Meningitis 8. Pre-eclampsia 9. Rabies 10.Reyes syndrome 11.Stroke 12.Vasovagal syncope 13.Postural hypotension 14.Hyperventilation 15.Cardiac arrhythmia 16.Hypoxia 17.Hypoglycaemia 18.Vertebra basilar transient ischemic attack 19.Epilepsy
  2. 2. TYPES Toxic-metabolic encephalopathy. This is an acute condition of brain dysfunction with symptoms of confusion and/or delirium. The condition is usually reversible. The causes of toxic-metabolic encephalopathy are varied. They include systemic illness, infection, organ failure, and other conditions. Anoxic brain injury. This is a brain condition caused by total lack of oxygen to the brain. Lack of oxygen for a few minutes causes cell death to brain tissues. Anoxic brain injury may result fromheart attack (cardiac arrest), head injury or trauma, drowning, drug overdose, or poisoning. Persistent vegetative state. This is a state of severe unconsciousness. The person is unaware of his or her surroundings and incapable of voluntary movement. With a persistent vegetative state, someone may progress to wakefulness but with no higher brain function. With persistent vegetative state, there is breathing, circulation, and sleep-wake cycles. Locked-in syndrome. This is a rare neurological condition. The person is totally paralyzed except for the eye muscles, but remains awake and alert and with a normal mind. Brain death. This is an irreversible cessation of all brain function. Brain death may result from any lasting or widespread injury to the brain. Signs&Symptoms The signs and symptoms of coma commonly include: Closed eyes Depressed brainstem reflexes, such as pupils not responding to light No responses of limbs, except for reflex movements No response to painful stimuli, except for reflex movements Irregular breathing Symptoms of a coma include the following: No response to outside stimuli, such as: o Pain o Sound o Touch o Sight
  3. 3. Spontaneous body movements, such as: o o o o o Jerking Shaking Trembling Eyes opening and closing Irregular breathing DIAGNOSIS • Diagnosis of coma is simple; however, diagnosing the cause of the underlying disease process often proves to be challenging. The first priority in treatment of a comatose patient is stabilization following the basic ABCs (standing for airway, breathing, and circulation). Once a person in a coma is stable, investigations are performed to assess the underlying cause. Investigative methods are divided into physical examination findings and imaging (such as CAT scan, MRI, etc.) and special studies . Diagnostic steps • When an unconscious patient enters a hospital, the hospital utilizes a series of diagnostic steps to identify the coma • Perform a general examination and medical history check • Make sure patient is in an actual comatose state and is not mistaken for locked-in state (patient will either be able to voluntarily move his eyes or blink) or psychogenic unresponsiveness • Find the site of the brain that may be causing coma (i.e. brain stem, back of brain…) and assess the severity of the coma with the Glasgow coma scale • Take blood work to see if drugs were involved or if it was a result of hypoventilation/hyperventilation • Check for levels of “serum glucose, calcium, sodium, potassium, magnesium, phosphate, urea, and creatinine”
  4. 4. • Perform brain scans to observe any abnormal brain functioning using either CT or MRI scans • Continue to monitor brain waves and identify seizures of patient using EEGs Initial assessment and evaluation • In the initial assessment of coma, it is common to gauge the level of consciousness by spontaneously exhibited actions, response to vocal stimuli ("Can you hear me?"), and painful stimuli; this is known as the AVPU (alert, vocal stimuli, painful stimuli, unresponsive) scale. More elaborate scales, such as the Glasgow Coma Scale, quantify an individual's reactions such as eye opening, movement and verbal response on a scale; Glasgow Coma Scale (GCS) is an indication of the extent of brain injury varying from 3 (indicating severe brain injury and death) to a maximum of 15 (indicating mild or no brain injury). • In those with deep unconsciousness, there is a risk of asphyxiation as the control over the muscles in the face and throat is diminished. As a result, those presenting to a hospital with coma are typically assessed for this risk ("airway management"). If the risk of asphyxiation is deemed to be high, doctors may use various devices (such as an oropharyngealairway, nasopharyngeal airway or endotracheal tube) to safeguard the airway. Imaging and special tests findings • Imaging basically encompasses computed tomography scan of the brain, or MRI for example, and is performed to identify specific causes of the coma, such as haemorrhage in the brain or herniation of the brain structures. Special tests such as an EEG can also show a lot about the activity level of the cortex such as semantic processing,presence of seizures, and are important available tools not only for the assessment of the cortical activity but also for predicting the likelihood of the patient's awakening. The autonomous responses such as the Skin Conductance Response may also provide further insight on the patient's emotional processing.
  5. 5. PROGNOSIS • The prognosis for a coma varies with each situation. The chances of a person's recovery depend on the cause of the coma, whether the problem can be corrected, and the duration of the coma. If the problem can be resolved, the person can often return to his or her original level of functioning. Sometimes, though, if the brain damage is severe, a person may be permanently disabled or never regain consciousness. • Comas that result from drug poisonings have a high rate of recovery if prompt medical attention is received. Comas that result from head injuries tend to have a higher rate of recovery than comas related to lack of oxygen. • It can be very difficult to predict recovery when a person is a coma. Every person is different and it is best to consult with your doctor. As we would expect, the longer a person is in a coma, the worse the prognosis. Even so, many patients can wake up after many weeks in a coma. However, they may have significant disabilities. MEDICAL MANAGEMENT EMERGENCY TREATMENT • Maintain ventilation oxygenation • Maintain circulation • Control seizure • Reduce icp • Maintain temperature • Control hypoglycemia Maintain ventilation • Insert oral airway • Clean oropharyngeal secretion
  6. 6. Some medicines used are as follows:• inj. Lorazepam 4mg • Inj diazepam 10-12mg • Inj phenytoin 15-20mg • Injmenintol 20% 1 gm/kg iv fast