Neurology Made Simple : Coma : Clinical Examination and Management

COMA : CLINICAL EXAMINATION AND MANAGEMENT:

CLINICAL EXAMINATION IN COMA

NEUROLOGICAL EXAM :

Pupillary size and reaction : Bilateral fixed and dilated pupils indicates severe damage and are a sign of poor prognosis.

A unilateral fixed dialted pupil indicates 3rd cranial nerve lesion commonly due to uncalherniation.

Unlateral Horner”s syndrome indicates damage to the hypothalamus or lateral medullary syndrome.

Bilateral small pupils is suggestive of opiodoverdose or pontine damage.

INVESTIGATIONS

Laboratory tests

Blood samples will be taken to check for:

Complete blood count

Electrolytes, glucose, thyroid, kidney and liver function

Carbon monoxide poisoning

Drug or alcohol overdose

A spinal tap (lumbar puncture) can check for signs of infections in the nervous system. During a spinal tap, a doctor or specialist inserts a needle into the spinal canal and collects a small amount of fluid for analysis.

Brain scans

Imaging tests help doctors pinpoint areas of brain injury. Tests may include:

Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create a detailed image of the brain. A CT scan can show a brain hemorrhage, tumors, strokes and other conditions. This test is often used to diagnose and determine the cause of a coma.

Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of the brain. An MRI can detect brain tissue damaged by an ischemic stroke, brain hemorrhages and other conditions. MRI scans are particularly useful for examining the brainstem and deep brain structures.

Electroencephalography (EEG). An EEG measures the electrical activity inside the brain. Doctors attach small electrodes to the scalp. Doctors send a low electrical current through the electrodes. The brain's electrical impulses are then recorded. This test can determine if seizures may be the cause of a coma.

MANAGEMENT OF COMA

A coma is a medical emergency.

Doctors will first check the affected person's airway and help maintain breathing (respiration) and circulation. Doctors may give breathing assistance and High flow oxygen, blood transfusions and other supportive care.

Establish iv access and monitor Oxygen saturations.

In case of hypoglycemia , if fingerprick glucose is less than 2.5 mmol/l give 50 ml of 50 % glucose iv.

In suspected opioid toxicity ,if pupils are small and respiratory rate is low ,give naloxone 400 mcg stat and repeated to a total of 1.2 mg .

Treatment varies, depending on the cause of the coma. A procedure or medications to relieve pressure on the brain due to brain swelling may be needed.

If the coma is the result of drug overdose, doctors will give medications to treat the condition. If the coma is due to seizures, doctors will administer medications to control seizures.

Other treatments may focus on medications or therapies to address an underlying disease, such as diabetes or liver disease.

Sometimes the cause of a coma can be completely reversed and the affected person will regain normal function. But if the affected person has suffered severe brain damage, he or she may sustain permanent disabilities or may never regain consciousness. The person may enter a persistent vegetative state or become brain dead.