2. Why coma management?
• Common medical emergency 3-5%
• Large proportion of comatose patient
recover
• Untreated coma may lead to further brain
damage

3. Check vital signs
• Respiration
• Pulse, BP,
• temperature.

4. Emergency treatment
• Maintain ventilation oxygenation
• Maintain circulation
• Control seizure
• Reduce icp
• Maintain temperature
• Control hypoglycemia

5. Maintain ventilation
• Insert oral airway
• Clean oropharyngeal secretion
• Insert cuffed endotracheal tube if apnea,
hypoventilation or liable to aspirate
• Mechanical ventilation if apnea or raised
intracranial pressure

6. Draw Blood for
• Start venous line
• Complete blood count, MP, B.sugar
• Blood urea, s. creatinine,
s.electrolyte
• Blood gases, ALT, AST
• Give 25% 100ml glucose with
100mg of thiamine

7. Maintain circulation
• If hypotenstion ( <90mmHg systolic)
– Replace fluid:
• Saline if hyperglycemia or suspected stroke,
diabetes
• Dextrose saline or isolyte if undiagnosed
– Vasopressor if low systolic pressure inspite of
fluid
• Hypertension: Betablocker, Nitroglycerine
or Nitropruside

8. Control Seizure
• Inj Lorazepam 4mg or Midazolam 5mg IV
slowly
• Inj Diazepam 10-20mg iv slowly
• Inj Phenytoin 15-20mg/Kg 50mg/min IV
• Inj Phenobarb 15-20mg/Kg 50mg/min IV
• Inj Sodium valproate 200-400mg IV

9. Reduce intracranial pressure
• Inj Mannitol 20% 1gm/kg IV fast
• Hyperventilatin to bring pCO2 25-30mmHg

10. Maintain Temperature
• Hperthermia: tapid sponging, largectil,
• Hypothermia: heating blanket

11. Is it Coma ?
• Posture: loss of erect posture
• Eye closed: sleep like state
• Lack of responsive ness

12. Psychogenic coma
• Holds eye tight, resist opening
• Fixed stare, quick blink
• Normal pupil
• Normal oculocephalic
• Normal oculovestibular
• Normal posture, breathing, bp,pulse

13. Spectrum of Coma
• Psychogenic unresponsiveness
• Acute confusional state
• Locked in syndrome
• Akinetic mutism
• Persistent vegetative state
• Brain death

14. What causes coma?
Metabolic:- Structural:-
– Ischemic hypoxic – Supratentorial bilateral
– Hypoglycaemic – Unilateral large lesion
– Organ failure with transtentorial
– Electrolyte disturbance herniation
– Toxic – Infratentorial

15. Metabolic encephalopathy
• Confusional state -> coma
• No focal neurological sign
• No neck stiffness
• Normal brainstem reflexes
• Coarse tremor 8-10hz
• Multifocal myoclonus
• Asterixis
• Generalized/periodic myoclonus

16. Supratentorial Lesions
• Epidural or Subdural Hematoma
• Large Ischemic Infarction
• Tumour
• Intraparenchymal haemorrhage
• Trauma
• Abscess

17. Infratentorial Lesions
• Basilar artery thrombosis
• Pontine or Cerebellar Hematoma
• Ischemic Cerebellar Infarction
• Tumour
• Abscess

18. History
• Circumstances and temporal profile
• Of the onset of coma
• Details of preceding neurological
• Symptoms headache, weakness seizure
• Any fall
• Use of drug and alcohol
• Previous medical illness liver,kidney
• Previous psychiatric illness

19. Other symptoms of coma
• Yawning • Vomiting
– Lateral reticular formation of
– Poor localizing value the medulla
– Posterior fossa expanding – Projectile ( usually nausea)
lesion – Medulloblastoma
ependymoma
– Medial temporal, third – Raised icp -> compression of
ventricular medulla
– Basal meningitis
• Hiccup – Ivh -> irritating fourth
– Medullary lesion in the region ventricle
of Third ventricle – Lateral medullary infarct
(vestibular

20. Examination
• General physical examination
• Evidence of external injury
• Colour of skin and mucosa
• Odour of breath
• Evidence of systemic illness
• Heart lung

21. Neurological examination
• Funduscopy
• Pupil size and response to light
• Ocular movements
• Posture and limb movement
• Reflexes

22. Circulation
Kocher-Cushing response - rise in BP-
>bradycardia due to rise in ICP ->
compression of floor of the iv ventricle fall
in BP and tachycardia usually terminal
event due to medullary failure

23. Breathing
• Forebrain
– Post hyperventilation apnea
– Cheyne stoke respiration
• Hypothalamus midbrain
– Central neurogenic hyperventilation
• Basis pontis
– Pseudobulbar paralysis of voluntary center

24. Breathing in coma
• Lower pontine tegmentum
– Apneustic breathing
– Cluster breathing
– Short cycle periodic breathing
– Ataxic breathing
• Medulla
– Ataxic breathing
– Slow regular respiration
– Gasping

25. Pupil
• Diencephalic (metabolic) Small reactive
• Midbrain tectal Midsize,fixed
• Midbrain nuclear Irregular pear shaped
• 3rd nerve Fixed widely dilated
• Pontine Pinpoint reactive
• Opiate Pinpoint
• Organophosphorus Small
• Atropine Wide dilated

26. Eye movement
• Metabolic
– Roving eye movement,
– Oculocephalic,
– Vestibuloocular
• Supratentorial
– Contralateral conjugate palsy
• Thalamus
– Upper turn down

27. Eye movements in Coma
• Midbrain
– Ipsilateral 3rd
• Pontine
– Ipsilateral 6th
– Ipsilateral gaze palsy
– One and half syndrome
– Bilateral gaze palsy
– Ocular bobbing
– Mlf syndrome

28. Posture
• Cerebral hemisphere • Upper brain stem
– Decorticate posture – Decerebrate posture
• Diencephalon • Pontine
supratentorial – Abnormal ext arm
– Diagonal posture – Weak flexion leg
• Medullary
– Flaccidity

29. ECG changes in coma
(SAH, ICH, INFARCT)
– Tall T, prolonged QT
– Q wave with st depression
– SVT, AF, AFL
– Sinus bradycardia,arrest, nodal rhythm
– A-V block or dissociation
– PVc's, VFL, VF

30. Further investigation
• CSF examination: neck stiffness without
localizing sign
• CT scan/ MRI: Focal neurological sign or
before LP
• X-ray chest: Aspiration, chest infection,
heart size
• Ultrasound abdomen: Liver, kideny, bladder

31. Agitated
1. Reassurance
2. Narcotics
– Small doses administered
– Intravenously
3. Sedation
• Should follow analgesia
• Sedation in presence of pain causes agitation,
• Titrate intravenously so that agitation is blunted,
• Do not induce excessive drowsiness

32. Agitated patient
5. General management
• Face a window for day/night orientation
• Clock, calendar
• Have friend or family member stay with patient
• Light the room if illusions, paranoia occur at night
• Provide eyeglasses, hearing aids
• Have staff identify themselves to patient
• Explain all procedures
• Provide radio, reading, TV

33. Coma Subsequent management
• Eye, mouth, skin
• Fluid electrolyte, feeding
• Respiration, circulation
• Urine, bowel
• Stimulation
• Infection