The document discusses altered levels of consciousness including coma. It defines coma as a state of deep unconsciousness where a person cannot be aroused and is unaware of their environment. Coma exists on a spectrum of consciousness that includes lethargy, stupor, and obtundation with decreasing levels of arousal. Causes of coma include structural brain issues, infections, trauma, vascular events, seizures, hypoxic or metabolic derangements. Immediate management of coma prioritizes airway, breathing, and circulation. Diagnostic workup includes assessments, labs, imaging, and lumbar puncture depending on findings. Treatment aims to address reversible causes and prevent complications through supportive care.

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Altered level of consciousness
(COMA)
Presented by: prepared by :
Reem farag Hameeda hussien

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Consciousness defined as being awake
and aware of both one’s self and
one’s surroundings, OR it is the
human awareness of both internal
and external stimuli
Introduction

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Altered Consciousness covers a spectrum of states:
Consciousness
Lethargy
Stupor or Obtunded
Coma
Introduction

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Lethargy: mild depression in level of consciousness
and can be aroused with little difficulty.
Obtund : More depressed level of consciousness and
can not be fully aroused. ( slow response and
sleepiness)
Stupor : Can not be aroused from a sleep like state.
( only respond by grimacing or drawing away
from painful stimuli)
Coma: More depressed level of consciousness and
unable to make any purposeful response.
Introduction

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 Derived from the Greek word ‘Koma’ or deep sleep
( It is an alteration of consciousness in which a
person appears to be asleep, cannot be
aroused even by painful stimuli, and shows
no awareness of the environment.)
Definition of coma

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 Normal consciousness is maintained by integrity of
certain areas of the cerebral cortex, thalamus and
brain stem
Pathophysiology

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 Altered consciousness due to:
Diffuse insult to both cerebral hemispheres
(metabolic/toxic/hypoxic/ischemic)
or
focal lesion affecting ascending reticular activating
system (ARAS) located in upper pons, midbrain &
diencephalon. Affected by compression
(herniation)
Pathophysiology

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Cranial Causes:
Structural
 CNS infections
 Mass lesions  CSF obstruction + ↑ volume
 Trauma
 Vascular
Functional
 Seizures
 Hypoxic - ischemic injury
Etiology

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Etiology
 Systemic shock
 hypo/ hypernatremia
 hypoglycemia
 diabetic coma
 hepatic
 uremic
 hypoxia
 Respiratory failure
 Acidosis/ alkalosis
Extracranial causes
Metabolic

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Etiology
 Barbiturates
 benzodiazepines
 Opioid s
 antihistamines
 Iron
 Salicylates
 Metals
Extracranial causes
Drugs

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Etiology
 Lead
 gram negative
endotoxemia
 Shigella
 CO poisoning
 pesticides
 alcohol/
ethylene glycol
Extracranial causes
Toxic

12. 
Etiology
Endocrine
 hypothyroidism
 diabetic
Miscellaneous
 hypertensive encephalopathy
 heat stroke
 hypothermia
Psychogenic
Extracranial causes

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 Coma is an acute life-threatening neurological
emergency
 Requires prompt intervention for preservation of
life & brain function
 So the ABC are the initial priority
Immediate Management

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 A – airway  prevent tongue falling back, suction
 B – breathingrespiratory support, oxygen
 C- circulationiv fluids, monitor BP, vasopressors
 If any evidence of poisoning  GL
Immediate Management

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 Circumstances?
 Duration & onset? Acute in CNS infection, trauma,
seizure, poisoning, metabolic, vascular
 H/o poisoning?
 H/o trauma?
 H/o fever?
 H/o seizure?
 Past medical history
 H/o seizures in the past?
 H/o known endocrine disorder?
 H/o headache/vomiting/visual symptoms?
Quick History & Examn

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 Vitals
 Fever
 BP
 S/o shock
 S/o ↑ ICP bradycardia, hypertension
 Respiration  rapid in acidosis & CNS lesions also
 General Physical:
 Evidence of trauma, injury, tongue bite
 Jaundice
 Breath - for odor of ketones, fetor hepaticus etc
 Skin peticheae, exanthem
 Moist skin with ↑salivation in organophosphorus
poisoning
 Complete systemic exam
Quick History & Examn

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 The goal of neurologic examination are:
 To determine depth of coma.
 To localize the process leading to coma.
 Includes
 Level of consciousness (Glasgow coma scale)
 Pupillary responses
 Eye movements(spontaneous or induced)
 Motor response
 Meningeal signs
 Sign of increased ICP
Neurological Examn

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ACTIVITYACTIVITY
BEST RESPONSEBEST RESPONSE
Adults/Older ChildrenAdults/Older Children Infants ( modified GCS )Infants ( modified GCS ) ScoreScore
Eye OpeningEye Opening
( E )( E )
1.1. SpontaneousSpontaneous
2.2. To speechTo speech
3.3. To painTo pain
4.4. NoneNone
1.1. SpontaneousSpontaneous
2.2. To speechTo speech
3.3. To painTo pain
4.4. NoneNone
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33
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VerbalVerbal
( V )( V )
1.1. Appropriate speechAppropriate speech
2.2. Confused speechConfused speech
3.3. Inappropriate wordsInappropriate words
4.4. Incomprehensible orIncomprehensible or
none specific soundsnone specific sounds
5.5. NoneNone
1.1. Coos, babblesCoos, babbles
2.2. Irritable, cries butIrritable, cries but
consolableconsolable
3.3. Cries, inconsolableCries, inconsolable
4.4. Moans to painMoans to pain
5.5. NoneNone
55
44
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MotorMotor
( M )( M )
1.1.Obeys commandsObeys commands
2.2.Localizes painLocalizes pain
3.3.Withdraws to painWithdraws to pain
4.4.Decorticate to painDecorticate to pain
5.5.Decerebrate to painDecerebrate to pain
6.6.NoneNone
1.1. Normal spontaneousNormal spontaneous
movementmovement
2.2. Withdraws to touchWithdraws to touch
3.3. Withdraws to painWithdraws to pain
4.4. Decorticate to painDecorticate to pain
5.5. Decerebrate to painDecerebrate to pain
6.6. NoneNone
66
55
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Glasgow coma scale

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Size and reactivity of pupils
Pupils Lesion/Dysfunction
Pinpoint Pons, opiates, cholinergic intoxication
Mid position –
fixed or irregular
Midbrain lesion
Unilateral ,
dilated and fixed
Uncal herniation
Bilateral , dilated
and fixed
Diffuse damage, central herniation,
global hypoxia ischemia, barbiturates,
atropine

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Eye movements

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Motor response

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Meningeal signs

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 The signs of raised ICP includes:
1- abnormal respiratory pattern.
2- unequal or unreactive pupils.
3-impaired or absent oculocephalic or
oculovestibular responsees.
4- systemic hypertension, bradycardia.
5- tense fontanelle.
6- abnormal body posture or muscle flaccidity.
S/o ↑ICP

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 Blood:
CBC, clotting and bleeding time
Glucose, electrolyte, urea, liver function test,
ammonia, and lactate
 Toxocology:
Urine, blood,gastric aspirate for ingestion
 Acid-base:
ABG
Investigations

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 Microbiology:
Blood and urine cultures
 Imaging:
CT , MRI
 Lumbar puncture – CI if ↑ICP. Abnormal in CNS
infections
Investigations

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 ABCs:
 Intubate if GCS ≤8 or respiratory failure
 Stabilize cervical spine
 Supplement O2
 IV access
 Blood pressure support as needed
 Dextrose 0.25 g/kg (2.5 mL/kg of 10 % dextrose
solution)
 Treat definite seizures. Lorazepam (0.1 mg/kg,
maximum single dose 5 mg). If seizures continue
treat as for status epilepticus.
Treatment

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 Infection:
 Ceftriaxone 100 mg/kg (maximum single dose 2
grams) and Vancomycin
 Acyclovir
 Ingestion:
 Naloxone 0.1 mg/kg IV; maximum 2 mg IV (use if
opioid toxidrome: miosis, respiratory depression,
hypotonia)
 Increased ICP:
 Mannitol 0.5 - 1 gram/kg IV
Treatment

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 Nursing care:
Position
Nutrition
Care of eyes
Care of skin
Chest physiotherapy
Care of bowel & bladder
Physiotherapy
Treatment

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Thank You!