This document provides an overview of the approach to evaluating and managing a patient presenting with coma in the emergency department. It begins by defining coma and outlining the pathophysiology involving impaired arousal from damage to the brainstem arousal system or cerebral cortex. The primary and secondary surveys are described which involve assessing the airway, breathing, circulation, disability and exposure. Differential diagnosis, common etiologies, ancillary testing, imaging and disposition are discussed. The key steps in the emergency department include stabilizing the airway and breathing, obtaining vital signs, blood glucose, brief history, full examination, imaging of the head and further testing and treatment based on diagnosis.

1. Approach to coma in ED
Runal Shah
PGY1
MEM, KDAH

2. Case Scenario
 43/Male brought to ED by Cardiac
ambulance at 11.00 am
 c/o unresponsiveness x 7.00 am
 A – Snoring sounds,
 B – breathing equal chest rise, RR 10/min
 C – cold periphery, BP- 170/90, P-110/min
 D – GCS E1,V2,M2 – Pupils 1.5mm sluggish
How will you evaluate ??

3. Definition
 COMA – Deep sleep like state from which
the patient cannot be aroused.
o Vegetative state
o Catatonia
o Akinetic mutism
o Locked in state

4. Pathophysiology
 Consciousness – Awareness of the self or surroundings
 Cognition – Orientation + Judgment
 Arousal – Level of Consciousness (Fully aroused to Comatose)
 ARAS – Anatomically located in Paramedian tegmental
zone of dorsal midbrain – responsible for arousal and
cortical activation
 Cerebral cortex – contains Cognition centers –
determine content of consciousness
 Insult to cerebral cortex or brainstem can independently
cause Coma; vulnerable to Metabolic derangements,
Toxins, Mechanical Injury.
 If ARAS is impaired, cerebral cortex cannot be aroused.

6. Differential Diagnosis
 Neurologic
 Infectious
 Metabolic
 Toxic
 Pulmonary, hypoxia
 Cardiovascular

9. Etiology
Structural
 Trauma
– SDH
– EDH
– Cerebral Concussion-
Contusion
 Stroke Syndromes
– Embolism
– Thrombosis
– Hemorrhagic
 Tumors
 Infections
Age related
 Infant
– Infection
– Trauma/ Abuse
– Metabolic
 Child
– Toxic ingestion
 Adolescent/ Young Adults
– Toxic
– Recreational Drug
– Trauma
 Elderly
– Meds/ OTC drugs
– Infection
– Stroke

10. Approach in ED
 Primary Survey
– Airway
– Breathing
– Circulation
– Disability (GCS, Pupils, NIHSS)
– Exposure
 Vitals
 Blood glucose
 Brief History of events (SAMPLE)
 Secondary Survey (Head to toe)

11. Primary Survey
 Airway:
 Patent / Compromised ?
 Intervene for Hypoxia / Obstruction / Dyspnea
 Proper position / Head tilt- Chin lift / Jaw thrust
 Oxygen Supplementation
 Nasal Prongs, Face mask, Venturi mask, Non-
rebreathing mask, Bag-Mask, ET intubation
 OPA, NPAs

12. Primary Survey
 Breathing:
 Equal chest rise?
 Use of accessory muscle
 Air entry bilateral equal?
 Adventitious sounds – Crepts/ Rhonchi/ Stridor ?

13. Primary Survey
 Circulation:
 Peripheries Cold/ Warm, Capillary Refill Time
 Blood pressure
 Pulse : Rate, Rhythm, Volume
 Intravenous Access – Blood collection & Sugars
 IV fluids according to Blood sugars

14. Primary Survey
 Disability:
 GCS (E V M)
 Pupils –
Size, Shape
Reactivity to light
Conjugate movements
NIHSS scoring
C-Spine immobilization in case of Trauma

15. History
• Trauma
• Cardiac arrest
• Drug overdose/ ingestion
• Neurological-
– Circumstances & rapidity
– Antecedent symptoms – Confusion, weakness,
headache, fever, seizures, double vision, vomiting
– Use of Meds, Drugs and Alcohol
– Chronic liver, kidney, heart, other medical disease
• Direct interrogation with Family members,
bystanders, Ambulance staff/ paramedics

16. Brainstem Reflexes
 Pupillary signs
– Examine with bright diffuse light
– Shape, size, reactivity
– Anisocoria?
 Ocular movements
– Spontaneous movements?
– Conjugate deviation
– Doll’s eye
– Ocular bobbing/ dipping
 Respiratory pattern
– Shallow slow regular breathing
– Cheyne-Stokes
– Kussmaul
– Agonal gasp

17. Immediate Interventions
 Intravenous Access
 Oxygen supplement
 Cardioscope monitoring
 Blood glucose
 ECG
 Emergent Head CT

18. Ancillary Testing
 Blood Glucose
 Arterial / Venous Blood gas
 Electrolytes
 Serum creatinine, BUN
 CBC
 Coagulation – PT, aPTT
 Thyroid profile
 Urine routine and Toxicology screening

19. Imaging
 Radiology
 CT Brain Plain
 CT Brain + Neck Angiography
 MRI Brain + MRAngiography
 Chest X-Ray
 Ultrasound
_______________________________
 ECG
 EEG

20. Algorithm

21. Disposition
 Depending on diagnosis, patient goes to
Intensive care unit (ICU) /Operation room (OR)
 Hypoglycemia patient requires ED observation,
and admission in ICU if Sugars are borderline
or mentation doesn’t improve.

22. Thank You…
Ref:
Harrison's Principles of Internal Medicine,19E
Rosen's Emergency Medicine,8ed