Coma

Question 1

Causes of impaired conscious level/coma -
Metabolic:

Answer 1

1. Drugs / poisoning - carbon monoxide, alcohol, tricyclics
2. Hypoxia, CO2 narcosis (COPD)
3. Hypothermia
4. Hypoglycaemia, hyperglycaemia - DKA or HONK
5. Septicaemia
6. Endocrine - Myxoedema, Addisonian crisis
7. Hepatic/ uraemic encephalopathy

Question 2

Causes of impaired conscious level/coma -
Neurological:

Answer 2

1. Trauma
2. Infection - meningitis/ encephalitis, eg herpes simple (give IV aciclovir)
3. Tropical: malaria (do thick films), typhoid, typhus, rabies, trypanosomiasis
4. Tumour: 1° or 2°
5. Vascular: stroke, subdural/subarachnoid, hypertensive encephalopathy
6. Epilepsy: non-convulsive status or post-ictal state

Question 3

Approach to Mx coma:

Answer 3

1. ABC
2. IV access
3. Stabilise C spine
4. Blood glucose - give 50mls of 20% glucose IVI stat
5. Control seziures
6. Rx causes
7. Quick Hx & Exam
8. Investigations - ABG/ FBC/ U&E/ LFT/ CMP/ ESR/ CRP/ ethanol/ toxic screen/ drug levels/ Blood cultures/ urine culture/ consider malaria/ CXR/ CT head
9. Reassess the situation & plan further investigations

Rx causes: Wernicke’s encephalopathy - IV thaimine, opioid OD - IV naloxone 0.4 - 2 mg, BZD OD - IV flumazenil

Question 4

GCS - Eye opening:

Answer 4

1. None
2. In response to pain
3. In response to speech
4. Spontaneous

Question 5

GCS - Verbal response:

Answer 5

1. None
2. Incomprehensible sounds
3. Inappropriate speech
4. Confused conversation
5. Orientated

Question 6

GCS - Motor response:

Answer 6

1. No response to pain
2. Extensor response - decerebrate posture
3. Flexor response - decorticate posture
4. Withdrawing to pain
5. Localising pain
6. Obeying commands

Question 7

Decorticate posture implies damage at which level?

Answer 7

1. Above the level of the red nucleus in
   the midbrain

Question 8

Decerebrate posture implies damage at which level?

Answer 8

1. Below the level of the red nucleus in
   the midbrain