coma-160807185638.pdf

Loss Of
Loss Of
Consciousness
Consciousness
Dr. Mohamed El-Abiad

Approach to the Comatose Patient
Initial Treatment
 Circulation
 Airway
 Breathing
 ABC - identify and address life threatening
inadequacies
 Treat rapidly progressive metabolic disorders
 Evaluate for intracranial hypertension and
imminent herniation and treat

Management of the Comatose Patient
Circulation
 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

 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

Airway
 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

Breathing
 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..

Glasgow Coma Scale
Glasgow Coma Scale
Three components. Score derived
by adding the score for each
component.
• Eye opening (4 points)
• Verbal response (5points)
• Best motor response (6 points)

 Eye opening
• 4 - spontaneous
• 3 - to speech
• 2 - to pain
• 1 - none
 Verbal Response
• 5 - oriented
• 4 - confused conversation
• 3 - inappropriate words
• 2 - incomprehensible sounds
• 1 - none
 Best Motor Response
• 6 - obeys
• 5 - localizes
• 4 - withdraws
• 3 - abnormal flexion
• 2 - abnormal extension
• 1 - none
Glasgow Coma Scale
Glasgow Coma Scale

Glasgow Coma Scale
Glasgow Coma Scale
Score > 13 …… Fully Consciousness
Score < 3 …… Deeply Comatosed
Between 3-13 …… Disturbed Consciousness

Management and Evaluation of the Comatose Patient
Practicalities
 During ABC’s and Tests:
– Have someone start IV and obtain labs
 ABG’s
 Toxin screens
– As soon as IV in and give
 Glucose (D25, 2 - 4 cc per kilogram)
 Consider thiamin

Intra Cranial
Intra Cranial
Causes
Causes
Extra Cranial
Extra Cranial

Pupil Size
Pupil Direction
Deviation Of Angle Of mouth
Salivation
Buccinator Muscle
Hypotonia
Positive Babainiski Sign

Pulse
Pupil
Patient
Blood Pressure Dr. Mohamed El-Abiad

Hypertension
Hypertension

Edema
Edema
Hemorrhage
Hemorrhage

Subdural Hematoma
Subdural Hematoma

Acute epidural hematoma and midline shift
Acute epidural hematoma and midline shift

Herniation syndromes
Herniation syndromes

Hypertension
Hypertension
Lasix
Capoten
Nitroglycerin

Diabetic
Diabetic

Hypoglycemia (Low Blood Sugar
Hypoglycemia (Low Blood Sugar
(
(
CAUSES:
Too little food, too much insulin or diabetes
medicine, or extra exercise.
ONSET: Sudden, may progress to insulin shock.
BLOOD SUGAR: Below 70 mg/dL. Normal range: 70-115 mg/dL
WHAT CAN YOU DO?
Drink a cup of orange juice or milk or eat several
hard candies
Test Blood sugar
Within 30 minutes after symptoms go away, eat a
snack e.g. sandwich, and a glass of milk
Contact doctor if symptoms don't stop

Hyperglycemia (High Blood Sugar
Hyperglycemia (High Blood Sugar
(
(
CAUSES: Too much food, too little insulin, illness or stress.
ONSET: Gradual, may progress to diabetic coma.
BLOOD SUGAR:
Above 200 mg/dL.
Normal range: 70-115 mg/dL
WHAT CAN YOU DO?
Test blood sugar
If over 250mg/dL for several tests, CALL YOUR
DOCTOR!

Diabetic ketoacidosis

Symptoms
Nausea and vomiting
Fruity breath (breath odor(
Stomach pain
Deep, rapid breathing
Flushed face
Dry skin and mouth
Muscle stiffness or aching Headache
Shortness of breath Decreased consciousness
Decreased appetite Abdominal pain Fatigue
Breathing difficulty while lying down
Frequent urination or thirst for a day or more
Mental stupor that may progress to coma

Testing for Diabetic Ketoacidosis
Testing for Diabetic Ketoacidosis
Ketone testing may be used in type 1 diabetes to screen for early ketoacidosis.
The ketones test is done using a urine sample.
Ketone testing is usually done at the following times:
•When the blood sugar is higher than 240 mg/dL
•During an illness such as pneumonia, heart attack, or stroke
•When nausea or vomiting occur
•During pregnancy
Other tests that may be done to
diagnose ketoacidosis include:
•Arterial blood gas
•Blood glucose test
•Blood pressure measurement
•Amylase blood test
•Potassium blood test

Ketoacidosis
Ketoacidosis
Insulin
NaHCO3
IV Fluids

Hepatic Encephalopathy
Hepatic Encephalopathy

Causes
Causes
:
:
(1( Virus hepatitis
(2( Cirrhosis of liver,
(3( Biliary cirrhosis,
(4( Toxic hepatitis,
(5( Infantile cirrhosis of liver,
(6( Hepato toxic drugs,
(7( Carcinoma of liver,
(8( Portal hypertension,
(9( Toxic nitrogenous products are absorbed from the large gut
(10(Defective synthesis of urea in the liver, etc.

Triggered by
Triggered by
:
:
•Dehydration
•Eating too much protein
•Electrolyte abnormalities (especially a decrease in potassium(
from vomiting or taking diuretics
•Bleeding from the intestines, stomach, or esophagus
•Infections
•Kidney problems
•Low oxygen levels in the body
•Shunt placement or complications (portosystemic shunt (
•Surgery
•Use of medications that suppress the central nervous system
(such as barbiturates or benzodiazepine tranquilizers(

Signs and Symptoms
Signs and Symptoms
:
:
Symptoms many begin slowly and gradually worsen,
or they may begin suddenly and be severe from the start.
(
A( Stage of pre-coma
(
1
(
Alteration in behaviour
.
(2( Impairment of memory and other intellectual functions.
(3( Confusion and even delirium.
(4( Slurring of the speech.
(5( Inversibn of sleep rhythm.
(6( Convulsion—local or generalised.
(7( Restlessness
(8( Disorientation about space time and persons.
(9( Flapping tremor in the outstretched hand and fingers,
wrist and even in the shoulder (Bat’s wing tremor(.

Signs and Symptoms
Signs and Symptoms
:
:
(B( Stage of coma
(
1
(
Patient is in deep coma
,
(2( Muscles are flaccid.
(3( Planter may be extensor absent.
(4( Deep reflexes absent. [Cerebral disturbance (encephalopathy(]

Diagnosis
Diagnosis
:
:
• Complete blood count or hematocrit to check for anemia
• CT scan of the head
• EEG
• Liver function tests
• Prothrombin time
• Serum ammonia levels
• Sodium level in the blood
• Potassium level in the blood
• creatinine to see how the kidneys are working
Signs of liver disease, such as:
yellow skin
eyes (jaundice(
fluid collection in the abdomen (ascites(
occasionally a musty odor to the breath and urine
Tests may include
:

(1( Complete bed rest.
(2( Diet should contain more carbohydrate and less protein.
(3( Sedatives
(4( Good food and polyvitamins may be effective.
(5( Drugs—sedate cause of anxiety and treated
(6( Gastrointestinal bleeding must be stopped
(7( Infections, kidney failure, electrolyte abnormalities
(especially potassium( need to be treated.
(8( Life support may be necessary to help with breathing
or blood circulation, particularly if the person is in a coma.
(9( Lactulose may be given to prevent intestinal bacteria from
creating ammonia , and as a laxative to remove
blood from the intestines. Neomycin may also be used to
reduce ammonia production by intestinal bacteria.
(10( Medications containing ammonium (including certain antacids
should also be avoided.
Treatment
Treatment

Complications
Complications
Prognosis
Acute hepatic encephalopathy may be treatable.
Chronic forms of the disorder often keep getting
worse or continue to come back.
Both forms may result in irreversible coma and death.
Approximately 80% (8 out of 10 patients) die
if they go into a coma. Recovery and the risk of the condition
returning vary from patient to patient.
•Brain herniation
•Brain swelling
•Increased risk of:
•Cardiovascular collapse
•Kidney failure
•Respiratory failure
•Sepsis
•Permanent nervous system damage
•Progressive, irreversible coma
•Side effects of medications

Renal Failure
Earthy Looking
Puffiness of eyelid in the morning
Lower limb edema

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