Coma

Question 1

What is the definition of a coma?

Answer 1

“A state of profound unconsciousness caused by disease, injury or poison. The patient is unresponsive and cannot be roused”

Question 2

How long can comas last?

Answer 2

May be transient phenomenon during an acute illness or may persist in the long term

Question 3

What are patient’s like during a coma?

Answer 3

Alive but unable to perceive or react meaningfully to external environment

Question 4

How is a patient’s alertness assessed?

Answer 4

Glasgow Coma Score (GCS), AVPU

Question 5

What is the highest score for GCS and what does it mean?

Answer 5

highest score = 15, indicates normal conscious level

Question 6

What is the lowest score and what does it mean?

Answer 6

lowest score = 3, indicates deep coma or death

Question 7

What does a GCS < 8 mean

Answer 7

severe reduction in conscious level and the patient is unlikely to be able to maintain their airway spontaneously so should be intubated and ventilated

Question 8

What does AVPU stand for? (and what do they mean)

Answer 8

Alert - spontaneous eye opening, speaking and intact motor functions
Voice - responds when spoken to whether normal speech or a grunt
Pain - responds to pain e.g. sternal rub
Unresponsive

Question 9

What are metabolic causes of coma?

Answer 9

• drugs, poisoning e.g. carbon monoxide, alcohol, tricyclic antidepressants
• hypoglycaemia
• hyperglycaemia
• hypoxia
• CO2 narcosis ( COPD)
• septicaemia
• hypothermia
• myxoedema, addisonian crisis
• hepatic/uraemia •encephalopathy

Question 10

What are neurological causes for coma?

Answer 10

• trauma
• infection - encephalitis, meningitis
• tropical infection - typhoon, typhus, rabies
• brain tumour - primary or secondary
• Vascular - subdural/subarachnoid haemorrhage, hypertensive encephalopathy
• epilepsy: non-convulsive states or post-ictal state

Question 11

What is immediate management of coma?

Answer 11

ABCDE !!!
•intubation and ventilation if GCS < 8
•IV fluids to support circulation
•give oxygen
• treat any seizures
• check blood glucose (give IV glucose if hypoglycaemia suspected)
•IV thiamine if indication of Wernicke’s encephalopathy
•IV Naloxone for opitate intoxication
• IV flumazenil for benzodiazepine overdose

Question 12

What would you examine in coma?

Answer 12

VITAL SIGNS !!!!
•signs of trauma - haematoma, laceration, bruising, CSF or blood in nose or ears,
• stigmata of any other illnesses e.g. liver disease, diabetes, myxoedema
•check skin - needle marks, pallor, cyanosis, rash, poor turgor
•smell breath - alcohol, ketosis, hepatic fetter, uraemia
• opisthotonus
•meningism
• pupils : size, reactivity, gaze
• resp/cardio exam
• abdomen, rectal
• any foci of infection