1. The document discusses the approach to evaluating and managing a comatose patient. It defines consciousness and the components of arousal and content of consciousness. 2. Evaluation of a comatose patient involves obtaining a detailed history, performing a physical exam including neurological assessment of pupil size and reactivity, eye and motor movements, and determining the level of coma. 3. Management begins with addressing airway, breathing, and circulation (ABCs), treating potentially life-threatening metabolic disorders, evaluating for increased intracranial pressure, and providing supportive care measures.

1. Approach to comatose patient
Mohamed rizk khodair
Lecturer of neurology
Mohamedrizk.med@o6u.edu.eg
October 6 university

2. Objectives
1. Consciousness.
2. Definition of coma
3. Causes of coma
4. Evaluation of a comatose patient.
5. How to manage a comatose patient.

3. Consciousness
Two components of conscious behavior
Content of consciousness:
the sum of cognitive and emotion( memory , attention , thinking )
State of consciousness (Arousal ):
Physiological state of being aware or reactive to stimuli.
Content depends on arousal, but normal arousal does not guarantee normal
content
• Awareness of self and environment

4. The content of consciousness depends upon the activities of the cerebral
cortex, the thalamus and their interrelationship.
Lesions of these structures will diminish the content of consciousness without as a
rule changing the state of consciousness.

5. Arousal: where is it localized?
Ascending Reticular
Activating System (ARAS)
‘core of the brainstem’
receives input from numerous
somatic afferents
projects to midline thalamic
nuclei (which are in a circuit with
cortical structures) and the limbic
system.

6. Inattentive persons are usually unable to do more than simplest
commands.
Speech is usually limited to a few words or phrases
Disoriented in time and place.
Confusion

7. Inability to sustain a wakeful state without the application of external stimuli.
The lids droop without closing completely; there may be snoring, the jaw and limb muscles are slack,
and the limbs are relaxed.
Drowsiness

8.  Patient can be roused only by vigorous and repeated stimuli.
 Response to spoken commands is either absent or slow and inadequate.
 When left unstimulated, patients quickly drift back into a sleep-like state.
 The eyes move outward and upward, a feature that is shared with sleep
 Tendon and plantar reflexes and breathing pattern may or may not be altered.
Stupor

9.  Unconscious and Incapable of being aroused by any stimuli however vigorous and painful.
 Eye closed.
 Absent sleep-wake cycle.
Coma

11. Evaluation
1-History
Recent events
When patient last seen?
How was the patient discovered?
Any preceding neurological complaints?
Any trauma?
Drug exposure?
Medical history.
Psychiatric history.
Medication.
Alcohol.

12. 2-General Physical examination
Vital signs:
Severe HTN (hypertensive encephalopathy or structural lesion with increase ICP).
Skin: signs of trauma & needle mark, rash& jaundice.
Breath: alcohol & acetone ( diabetic ketoacidosis ) & fetor hepaticas ( hepatic coma ).
Head: fracture& hematomas& laceration.
Ear, nose and throat: CSF otorrhea or rhinohea &hemotympanum & tongue biting.
Neck (not manipulate if suspect of cervical spine fracture): stiffness.

13. 3-Neurological examination
The goals of neurological examination are :
1) To localize the process leading to coma.
2) To determine the depth of coma.

14. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response

15. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response
Eye lid:
Closed lower Pons intact.
Blinking Psychogenic .
Puffiness renal &myxedema.
Open eye lids and slack jaw indicate
deep coma.
Head and gaze deviation suggest a
large ipsilateral hemispheric lesion.
Observe for:
myoclonus (metabolic cause).
Seizures.
Tetany.

16. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response

17. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response
Symmetry and normal reactive:
mean integrity of midbrain.
Midposition (2-5mm) fixed or
irregular: focal brain stem lesion.
Pinpoint reactive pupils:
Pontine damage
Opiates
cholinergic intoxication.
Unilateral dilated and fixed pupil:
uncal herniating.
Bilateral dilated fixed pupil:
 central herniation.
Global hypoxic ischemia.
Barbiturate and atropine

18. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response

19. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response
1) Position of eye at rest:
 Gaze deviation away from the
hemiparesis :
Hemispheric lesion contralateral
side of hemiparesis.
 Gaze deviated toward the
hemiparesis:
• Pontine lesion (fovill syndrome).
• ‘Wrong –way gaze’ thalamic
lesion contralateral to
hemiparesis.

20. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response
Papilledema occurs
after prolonged (˃12h)
elevated of ICP.

21. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response
Afferent CN 5
Efferent CN 7

22. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response
In intubated
patients, this
reflex can be
tested by gently
manipulating the
endotracheal
tube.

23. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response
Cheyne-stoke resp.
Central hyperventilation
Apneustic breathing
Cluster breathing
Ataxic breathing

24. 1-General
appearance
2-Level of coma
3-pupil
4-Sign of meningeal
irritation
5-Ocular
movement
6-fundus
7-Corneal reflex
8-Gag reflex
9-respiration
10-Motor
response
Inspection:
Tone & reflexes
:symmetrical or not.
Response to painful
stimuli:
Flexor (decorticate)
posturing: damage of
corticospinal tracts at
deep hemisphere or
upper midbrain.
Extensor (decerebrate)
posturing: damage of
corticospinal tracts at
pons or upper medulla.

26. Management of the Comatose Patient
Airway
Breathing
Circulation
ABC - identify and address life threatening inadequacies
Treat rapidly progressive metabolic disorders -- hypoglycemia
Evaluate for intracranial hypertension and imminent herniation
and treat

27. Evaluate -- is airway patent. Can patient move air without
obstruction. Is there trauma or foreign body obstructing airway
Try chin lift to help open airway -- protect cervical spine
Place airway if indicated - nasal or oral airway, intubation, or
surgical airway
Airway

28. Intubate (protecting neck)
Any of the following are adequate criteria
GCS < 9
Airway not secure or open
Respiration not adequate
Any significant respiratory failure
Uncertainty regarding direction or rate of mental status changes, particularly if
constant observation not available (during CT scans, etc..)
Airway

29. Evaluate - is patient moving adequate air, is respiratory rate
appropriate, is gas exchange adequate, are breath sounds
adequate and symmetrical
Must assure oxygenation and ventilation
If intubated don’t forget to ventilate
Identify and immediately treat problems - pneumothorax,
airway obstruction, etc..
Breathing

30. Is patient in shock?
Check pulses, heart rate, blood pressure, perfusion
Remember hypotension is late sign of shock
Start treatment for shock
Do not restrict fluids in comatose patient with inadequate intravascular volume.
Cardiac output and cerebral perfusion are much more important than fluid restriction
Circulation

31. Use isotonic solutions and blood, as indicated.
Do not use hypotonic solutions to treat shock, particularly
patients with coma or possible cerebral edema
Identify life threatening hemorrhage and control it.
Circulation

32. During ABC’s and secondary survey:
Have someone start IV and obtain labs
ABG’s , Random blood sugar
Kidney function, LFT’s, ammonia, coagulation studies
Toxin screens
As soon as IV in and labs drawn, give
Glucose (D25, 2 - 4 cc per kilogram)
Consider thiamine

33. If scans normal, probably metabolic
Emergent causes of metabolic coma (even after ABC’s)
Hypoglycemia - give glucose
Infection - LP, consider antibiotics, acyclovir. If diagnostic studies delayed, treat
first
Certain toxins - antidepressants, salicylates, theophylline, alcohol (methanol
and ethylene glycol)
Subclinical status epilepticus

34. Nutrition: naso-gastric tube and fluid
replacement.
Skin: pt. be turned every 1-2 hours to prevent
DVT.
Bowel care:
•stool softener to avoid constipation.
•H2 blocker to prevent gastric ulcer.
Bladder care.
Joint mobility.
DVT prophylaxis

35. Thank you
Mohamedrizk.med@o6u.edu.eg