1. COMA

2. Objectives To roughly understand the anatomical basis of Consciousness
To know the common causes of coma
To know the basic management of patients with coma.

3. Definition Consciousness?
A state of awareness of self and environment and responsiveness to external stimulation and inner need.
- Adams -

5. Aetiology Metabolic -extrinsic: Alcohol substance abuse Drugs
heavy metals and poisons

6. Aetiology Metabolic -intrinsic: fluid (Shock) and electrolytes
Nutritional
Endocrine
Organ failure

7. Aetiology Structural - Supratentorial Traumatic Vascular Inflammatory
Neoplastic
Degenerative

8. Aetiology Structural - Infratentorial Traumatic Vascular Inflammatory
Neoplastic
Degenerative

10. Brain Herniation Supratentorial herniation Uncal (transtentorial)
Central
Cingulate (subfalcine)
Transcalvarial
Infratentorial herniation
Upward (upward cerebellar or upward transtentorial)
Tonsillar (downward cerebellar)

15. Workup How bad it is? Is it Coma? Is it metabolic x Structural?
Supra x Infra _tentorial?

16. Workup
ABC
History
[Hypoglycemia, B1 def., Narcotic, Benzodiazipine]  immediate correction
Physical examination

17. Workup
Physical examination
Medical exam.
Neurological exam.

18. Neuro-exam Goals -functional assessment!
-Is there structural brain damage?
-Supra x Infra tentorial?
-Differential diagnosis of Coma

19. Neuro-exam Consciousness: Responses to painful stimuli?
R/O locked in state,
Vegetative state,
Minimally conscious state
Glasgow-Coma scale

20. Neuro-exam Ocular: Hutchison's pupil -uncal herniation
Miotic sluggishly reacting to light – pontine
Midsized or Mydriatic fixed to light – Midbrain

24. Neuro-exam
Oculo-cephalic
Vestibulo-ocular

29. Neuro-exam Rest of Cranials: -Fundoscopy -V: blink
-VII: cheeks and Eyes: Eyelid release test
-Gag

31. Neuro-exam Respiratory patterns: Poorly localizing
Cheyne-Stokes : Supra-tentorial /metabolic
Central neurogenic hyperventilation: Midbrain/pons
Apneustic (short-cycle Cheyne-Stokes): pons/medulla
Ataxic (Biot): medulla
Intermittent: medulla

32. Neuro-exam Motor system Signs of hemiplegia -wrist-dropping test
Arm-dropping test
Legs-dropping test
Driven postures: Decorticate, Decerebrate.

36. Neuro-exam Meningeal Irritation Signs - Neck stiffness -Kernig’s sign
-Brudzniski’

38. Further assessment
. Investigations -Blood -Bed side -Imaging -Toxicology

39. Management Specific: Treat the cause
Non specific: ABC, Feeding, Positioning, physiotherapy, monitoring, nursing care, etc…