ConsciousnessState of wakefulness with awareness of self and surrounding .

ConfusionAltered consciousness (the subject

misinterprets his surrounding) .

Deliriumstate of high arousal ( acute confusion )

There is confusion and visual hallucination .

Stupor Is abnormal sleepy stat from which the

subject can be aroused by repeated stimuli .

Coma ( or unconsciousness ) Is a state in which a patient is totally unaware of both self and external surroundings.

Coma is not a disease. It is a symptom of disease or a response to an event.

Pathophysiology:A reduction in neuronal function resulting from disruption of cerebral cortical or brain stem integrity.

* Encephalopathy: hypoxia ischemia seizures and post ictal states

* Infection: encephalitis meningitis septicemia

* Pressure effects: cerebral edema hydrocephalus space occupying lesions

* Vascular:- hemorrhage : extradural, subdural, subarachnoid, intraventricullar- hypertensive encephalopathy

* Diseases of other systems:- hepatic coma- uremic encephalopathy- respiratory failure with C02 narcosis

* Endocrine:- adrenal insufficiency- DKA / hypoglycemia- hypothyroidism- hypopituitarism

* Exogenous intoxication:- sedatives- salicylates- heavy metals- carbon monoxide

* Fluid and acid-base balance:- H20, Na, K, Mg and Ca imbalance

* Trauma.

HistoryInfection:Fever, irritability, lethargy, poor feeding, rash,

seizure.

Metabolic:Hx of DM, hx of previous loss of consciousness, hepatomegaly, jaundice, oligurea, hypertension.

Poisoning:Ask about drugs in the family, tablets, and

alcohol.

Seizure:Past hx of seizure, neurocutaneous lesions,

developmental delay, abnormal eye movement, focal neurological signs.

Trauma:Hx of road traffic accident, fall, bruising, hemorrhage,

fractures.

Raised intracranial pressure:Headache, vomiting,focal neurological signs: ataxia, squint.Papilloedema, retinal hemorrhage.

Physical Examination

General Examination

Neurological Examination

In General Examination:

Vital Signs:-

IRREGULAR – Cardiac diseases ABSENT – Peripheral emboliFEEBLE – Circulatory collapse

PULSE

BLOOD PRESSURE

-CVA -hypertensive

encephalopathy

-Cardiogenic shock

-Septicemia -Addison’s disease

TEMPERATURE

FEVER

HYPOTHERMIA

-Drugs : Barbiturate -Circulatory failure

-Myxoedema

-Systemic infection : malaria -Meningitis / encephalitis

-Heat stroke

CYANOSICYANOSISS

JAUNDICJAUNDICEE

PURPURPURPURAA

SKIN SKIN RASHRASH

Skin and mucous membranes-:

Head - scalp-:

fractures, hematomas ,ant fontanels.

ENT-:

discharge, blood

Fundoscopy

Neck - Cx. Spine-:

fracture, neck stiffness, carotid pulses

Neurological examination

Determine level of consciousness by

GCS

* The Glasgow Coma Scale is used to determine the severity of a brain injury. It is often used at the emergency scene or emergency room.

* The scale is used as part of the initial evaluation of a patient, but does not assist in making the diagnosis the cause of coma

* Motor, verbal, and eye responses are rated.

Eye Opening

Spontaneous

To loud voice

To pain

None 

Spontaneous

To loud voice

To pain

None

4

3

2

1

Verbal Response

Oriented

disoriented and converses

inappropriate words

Incomprehensible sounds None

smile, follows objects .

spontaneous irritable cry

Cries only to pain

Moans to pain

None

5

4

3

2

1

Motor Response

Obeys commands

Localizes pain

Withdraws from pain

Abnormal flexion (decorticate posture)

Abnormal Extension (decerebrate posture)

None

Obeys commands

Localizes pain

Withdraws from pain

Abnormal flexion (decorticate posture)

AbnormalExtension (decerebrate posture)

None

6

5

4

3

2

1

GCS

Mild=13-15

Moderate=9-12

Severe=3-8

Minimum=3 - Maximum=15

Core Neurological Exam (for coma);

1)Respiratory rate2)Pupil3)Extra ocular muscle, function muscle 4)Motor exam5)Ciliospinal reflexes

Supra-orbital nail-bed sternum

METHODS OF ELICITING MOTOR RESPONSE

MOTOR RESPONSEMOTOR RESPONSE

PUPILS – SIZE AND REACTION TO LIGHT

Normal, reactive

DIENCEPHALICDIENCEPHALICSmall, reactive MIDBRAINMIDBRAIN

Large, fixed

III NERVE (UNCAL)III NERVE (UNCAL) dilated, fixed

PONSPONSpinpoint

METABOLICMETABOLIC

yes yes (brain (brain stem intact)stem intact)

no no (brain stem (brain stem damage)damage)

- Chyne-Stoke breathing (cerebral Chyne-Stoke breathing (cerebral hemisphere lesion)hemisphere lesion)

- Central Neurogenic - Central Neurogenic Hyperventilation (midbrain) Hyperventilation (midbrain)

- Apneustic breathing (pons) - Apneustic breathing (pons) - Ataxic breathing – gasping - Ataxic breathing – gasping

(medulla)(medulla)

Drugs screen(eg_salicylates --diazepam-narcotics-amphetamines)

-Routine biochemistry (urea-electrolytes-glucose-calcium-liver biochemistry)

-Metabolic and endocrine studies (TSH-serum cortisol)

-Blood cultures such as cerebral malaria(thick blood film)

-If the explanation remains unclear ,further investigation are needed.

INVESTIGATION

IMAGING

CT or MRI brain imaging may indicate an otherwise unsuspected mass lesion or

intracranial hemorrhage.

CSF examination

Lumber puncture should be performed in coma only after careful risk assessment .it is usually contraindicated when an intracranial mass lesion is a possibility .CT is necessary to exclude this. CSF examination is likely to alter therapy only if undiagnosed meningoencephalitis or other identifiable

infection is present.

lumbar lumbar puncturepuncture.….…

Electroencephalography

EEG is of some value in the diagnosis of metabolic coma and encephalitis .

Management of comatose patient

Immediate Therapy

Specific Therapy

A

B

C