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Coma

Coma. By Shireen Gupta. Definition. Consciousness State of awareness of self and the environment Coma Sleep-like state of unresponsiveness. No awareness of self or the environment. Alterations in Sensorium (seat of sensation). “Clouding of Consciousness”

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Coma

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  1. Coma By Shireen Gupta

  2. Definition • Consciousness • State of awareness of self and the environment • Coma • Sleep-like state of unresponsiveness. • No awareness of self or the environment

  3. Alterations in Sensorium(seat of sensation) • “Clouding of Consciousness” • reduced wakefulness alternating with irritability; Defect in attention • Delirium(acute confusional state) • disorientation, fear, irritability • altered perceptions of sensory stimuli • rapid onset • duration 5-7 days

  4. Obtundation(less than full mental capacity) • mild to moderate reduction in alertness • mental blunting • Stupor • asleep or behaviorally unresponsive • Aroused by repeated vigorous stimulation

  5. Comatose state A person in a coma cannot be: • awakened, • fails to respond normally to pain, light or sound • does not have sleep-wake cycles, and • does not take voluntary actions.

  6. Etiology • intoxication • metabolic abnormalities, • Pyschogenic/CNS diseases • Iatrogenic • Structural lesion • Medications

  7. Anatomy of Coma • Ascending Reticular Activating System (ARAS) • Diencephalon • Cerebral Cortex

  8. ARAS Underlying cause: • Damage to the Reticular formation of the hindbrainwhich is important in regulating sleep.

  9. Diencephalon (Thalamus) • Input from the ARAS • Output to the cerebral cortex • Bilateral injury required to produce coma

  10. Cerebral Cortex • Maintains awareness • Bilateral diffuse cortical dysfunction can result in coma • Focal lesion with mass effect • Vegetative state

  11. HISTORY • Allergies • Medications • Past medical history • Last meal • Event Ask GP, family and check medical records for this information

  12. Coma Examination • Examination of the comatose patient is an examination of the brainstem In the initial assessment of coma, it is common to gauge the level of consciousness by response to • vocal stimuli ("Can you hear me?") • painful stimuli; this is known as the AVPU (alert, vocal stimuli, painful stimuli, unconscious) scale. • Glasgow coma scale quantify individual reactions such as eye opening, movement and verbal response on a scale.

  13. The Glasgow coma scale • Neurological scale - a reliable, objective way of recording the conscious state of a person, for initial as well as continuing assessment. • A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and • Generally, brain injury is classified as: Severe, with GCS ≤ 8 Moderate, GCS 9 - 12 Minor, GCS ≥ 13

  14. Glascow Coma Score • Eye opening • spontaneous 4 • voice 3 • pain 2 • nil 1 • Best verbal • oriented 5 • confused 4 • inappropriate 3 • incomprehens. 2 • nil 1 • Best Motor • obeys 6 • localizes 5 • nl flexion 4 • decorticate 3 • decerebrate 2 • nil 1

  15. FOUR Score4 components • Eye responsesE4 • Motor responsesM4 • Brainstem reflexesB4 • RespirationR4 CP1199945-54

  16. Four ScoreEye Response .

  17. Motor Response

  18. Brainstem Response

  19. Respiration

  20. Laboratory • Electrolytes • Calcium & magnesium • CBC • Toxicology/drug screen

  21. Ancillary Studies • Head imaging • CXR • ECG • EEG

  22. Emergent Therapies • ABC’s • D50 • Narcan • Thiamine • Flumazenil

  23. References • SnellsNeuroanatomy • http://en.wikipedia.org

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