Coma is a state of profound unconsciousness where a person is unresponsive and unarousable. It can be caused by traumatic brain injuries, metabolic disorders, infections, toxins, and other conditions. A thorough medical exam including assessment of breathing, eye movements, cranial nerves, motor function and Glasgow Coma Scale is used to evaluate comatose patients. Diagnosis involves medical history, exams, lab tests, imaging and EEG to determine the cause. Treatment focuses on addressing the underlying cause, providing supportive care, and preventing complications. Prognosis depends on the cause and duration of coma, with longer comas generally associated with poorer outcomes.

1. COMA
DR. SHAFAQ SHAIKH
FCPS II TRAINEE

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. 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

4. NEUROANATOMY

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. CAUSES
 According to etiology
 Traumatic
 Metabolic
 Vascular
 Infectious
 Toxic
 Structural
 Psychogenic

8.  Focal versus nonfocal.
 Focal: intracerebral hemorrhage, ischemic
stroke, demyelinating diseases.
 Nonfocal: vascular, toxic, metabolic
conditions, nutritional
deficiencies, seizures, psychiatric conditions.
 Either: trauma, infections, tumors

9. DIAGNOSIS
 Medical History
 Physical Exam & Neurological Evaluation
 Eye Examination
 Laboratory Tests
 Imaging Studies
 EEG

10. Clues from History
 Onset of symptoms
 sudden onset
 fluctuations
 Associated neurologic symptoms
 Medications

11. 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.

12. 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.

13. Eye examination
Pupils (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

14. eye examination
 Corneal reflex
 Ciliospinal reflex
 Eye movements
 Oculocephalic/ calorics
 fundoscopy

15. 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)

16. Motor Exam
 Assess tone, presence of asterixis
 Response to painful stimuli
 none
 abnormal flexor
 abnormal extensor
 normal localization/withdrawal
 Reflexes

17. The Glasgow Coma Scale
EYE OPENING VERBAL RESPONSE MOTOR RESPONSE
Spontaneous 4 Oriented 5 Obeys command 6
To speech 3 Confused 4 Localizes pain 5
To pain 2 Inappropriate words 3 Withdraws 4
None 1 Incomprehensible words 2 Abnormal flexor posturing
3
None 1 Abnormal extensor
posturing 2

18. LABS
 Blood cp
 Blood glucose
 Serum eletrolytes
 Serum calcium
 ABGs
 Liver and renal function tests
 Toxicologic studies

19. Other investigations
 Imaging studies: CAT scan, MRI
 EEG, BCI
 LP

21. TREATMENT
 Recovery position

22. TREATMENT
 Appropriate treatment must be commenced
concomitantly with routine measures
 Treat according to the cause
 The "Coma Cocktail"
It's a mixture of thiamine 50mg , dextrose 50 %
(25g) , and naloxene 0.4-1.2 mg given
intravenously.

23. 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

24. Long term treatment
 preventing infections such as pneumonia
 maintaining the patient's physical state
(preventing bed sores, for example)
 providing adequate nutrition.

25. 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

26. THANK YOU