| ID | 111 |
|---|---|
| Name | COMA |
| Cause | Causes of Coma:
A. Trauma (head injuries)-
Cerebral contusion
Extradural haematoma
Subdural haematoma
B. Infections-Meningitis
Encephalitis
Cerebral abscess
Severe systemic infections
C. Metabolic disturbance-Diabetes mellitus- hypoglycaemia, ketoacidosis
Hyponatraemia
Uraemia,
Hepatic failure
Respiratory failure , Hypothermia/hyperthermia
D. Cerebrovascular disease (CVD)-
Subarachnoid haemorrhage
Intracerebral haemorrhage
Brain stem infarction/haemorrhage
Cerebral venous sinus thrombosis
E. Drug abuse or intoxication
Alcohol, barbiturates, narcotics, tranquilizers, carbon monoxide, heavy metals etc.
F. Others: |
| Signs Symptoms | |
| Diagnosis | Examination of Coma patients: A. General examination: Temperature: ¯ in hypothermia, in infection. Skin: Texture- course & dry in hypothyroidism. Color- jaundice, rashes etc. Presence of injection site- indication of insulin injection (DM) or drug abuse. Breath: Alkohol, ketones may be felt; a fector in hepatic failure & uraemia. Respiration: Cheyne stokes respiration- occurs in bilateral cerebral dysfuntion, upper brain stem lesion, incipiant toxicity, metabolic acidosis if there is CO2 retention. Kussmaul (acidotic) respiration- in diabetic ketoacidosis, uraemia. Central neurogenic hyperventilation: sustained, rapid, deep breathing seen in pontine lesions. Ataxic respiration: shallow, halting respiration occurs in medullary respiratory centre damage. B. Neurological examinations: Pupils: Dilatation of one pupil & no direct or consensual response to light (i.e fixed pupil): occurs with compression of the 3rd cranial nerve e.g with uncal herniation. Pin point light fixed pupil: pontine haemorrhage. Midposition or slightly dilated pupil: indicate damage of midbrain. Homer’s syndrome (unilateral): seen in hypothalamic disease or lesion. Fixed dilated pupil: indicates brain death. Midpoint pupil react to light: due to coma in metabolic origin or CNS depressant drugs. Fundi: * Papilloedema or retinal haemorrhage. % Occular movements: Dolls’ head eye response: a contraversive conju-gate eye deviation in response to brisk rotation of the head from side to side and flexion and extension. It is seen with cortical depression in lightly comatos patients. It is impaired or lost in deep coma, with brain stem lesion depending on the site of the lesion, brain death. Abnormalites to lateral gage: sustained conjugate lateral gage occurs towords the site of destructive llemisphere (eye look towords normal limb) Oculovestibular reflex: deviation of eye towords the irrigated ear done by ice water. It is usually done in the unconcious patient suspected with brain stem lesion. Ocular bobbling: sudden, brisk downword ‘diving eye movement’ seen in pontine haemorrhage. Motor response: Response to painful stimuli Tone of muscle Facial appearance Asymmetry of tendon reflex Asymmetry of planter response Asymmetry of decerebrate & decorticate posture. |
| Investigations | Investigations: 1. Urine exam (after catheterization)- for protein, blood, glucose, acetone. 2. Blood tests- T.C, D.C, Hb%, electrolytes, blood gases, pH, NPN, glucose, ammonia etc. 3. Lumber puncture & CSF exam- microscopic and culture when suspected meningitis, encephalitis or subarachnoid haemorrhage. 4. Blood cultures & analysis of body fluids for evidence of toxins. 5. Thyroid function, blood cortisol. 6. Skull X-ray, EEG, Echoencephalography, Brain scan, CT scan of the head, Cerebral angiography arid Pneumography are valuable aids in diagno-sing brain tumour and subdural haematoma. 7. Chest X-ray and X-ray of the other organs may’be indicated. |
| Management | |
| Introduction | It is a condition of persistent loss of consciousness from which a patient cannot be aroused even by the most painful stimuli. Less degrees of coma is called stupor. It may be due to mechanical destruction of the brain tissue or disruption of the brain metabolic processes. |
| History | |
| Etiology | |
| Clinical Features | |
| Preventions | |
| Treatment | Treatment: 1. The patient should be kept in a railed cot in a calm and quiet room. 2. A Ryle’s tube should be passed, the stomach contents are aspirated and to be sent for chemical test. 3. Ryles tube feeding- 3000 kcal/day should be maintained. 4. The bladder is to be catheterised and a sample of urine to be sent for sugar & acetone test 5. Change the posture from time to time. 6. Give oxygen inhalation if there is dyspnoea. 7. Tracheostomy may be done if there is airway obstruction. 8. Prophylactic antibiotics may be given. 9. Liquid paraffin drops on both eyes may be given. 10. Inside of the mouth is to be painted with 1% mercurochrome. 11. Body powder to be sprinkled over the skiri surface. 12. If there is low B.P foot end of the bed should be raised and i.v. fluid drip to be started. 13. Ice sponging may be done if there is hyperpyrexia 14. Proper fluid, electrolyte balance and nutrition with i.v glucose, saline solutions should be made until the patient is able to take food and drinks by mouth. Then nutrition may be maintained by glucose, horlicks, fruit juice, fructose etc. If there is no contraindication. 15. Specific mesaures particularly in cases of poisoning can be taken. 16. The underlying cause is to be treated. |
| Complications | |
| Prognosis | |
| Types | |
| Classification | Clinical grading of coma: (Glasgo Coma Scale):2 Assessment Score Eye-opening (E) - spontaneously 4 - to speech 3 - to pain 2 -nil 1 Best motor response (M) - obeys commands 6 - localises pain 5 - withdraws 4 - abnormal flexion to pain 3 - extensor response to pain 2 -nil 1 Best verbal response- - oriented 5 - confused conversation 4 - inappropriate words 3 - incomprehensible sounds 2 -nil 1 Coma Score = E + M+ V - Minimum 3 - Maximum 15 Score 1 5- full concious Score 3- deep coma |
| Observation | |
| Pathology |
© Pakistan Drug Directory. All Rights Reserved.
Designed By: Pakistan Drug Directory Team