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Coma

more about Coma


Vegetative state

  • The human brain functions at many levels of consciousness. In the most basic terms, it is "consciousness" that allows one to be aware of his world and the world around him. Consciousness is fluid in nature, and contains what we call "the mind", consisting of chains of thought.
  • Every day, our senses (touch, sight, smell, taste, hearing) transfer information from the outside world to the brain, using a cascade of electrical impulses and chemical interactions. Yet despite such observable functions, "the mind" as we know it is really more a mental construct or idea that we loosely assign to a series of phenomenon, than a definable concrete organ, like the heart, liver, or lungs.
  • Using previously recorded data (i.e., memories, desires, fears, habits, language, past response to pain, etc.), this entity known as "the mind" attempts to make sense of the stream of incoming stimuli by painting a picture on the "canvas of consciousness", from which we may draw meaning, and form a "construct" (i.e., of a tree, pain, love, etc.) of what we perceive, so that we may react accordingly.
  • Coma, quite simply, is a state of prolonged "unconsciousness", in which one is not able to respond appropriately to the incoming stimuli by reacting. It is characterized by various stages of alertness and function, with the deepest level nearly shut down. This is the last step before so-called death and, interestingly, resembles a deep sleep state from which one cannot be aroused (even though some have).
  • However, brain waves measured during coma differ from those typical of deep sleep. And while in coma, one may experience varying degrees of awareness, but not be able to respond.
  • Coma is also different from stupor, a state in which an unconscious individual eventually responds to repeated stimuli.

  • Depends on the stage
  • How fast the coma develops depends on the cause (e.g., in drug overdose it may develop gradually).
  • Lack of self-awareness
  • Unable to open eyes
  • Unable to respond to painful stimuli
  • Unable to speak
  • Lack of purposeful movement --
    1. There may be jerky movements of muscles, limbs, eyelids, etc.
    2. There may be tremors of muscles or limbs.
    3. There may be abnormal eye movements.
  • Lack of normal sleep-waking cycle
  • Impaired breathing
  • May be unable to breath without mechanical ventilation
  • Coma may last for months or years.
  • Most patients die within the first few weeks of hospital admission with coma.

  • Coma results from an insult or injury to the brain that affects the structure or metabolic activities of the brain. Damage is divided into two kinds -- those that occur inside the brain, and those that occur outside.
  • Intracranial (within the brain) causes:
    1. Infections -- Meningitis, Encephalitis, Abscess
    2. Bleeding within the skull affecting the structure of the brain -- intracerebral, subdural, subarachnoid, extradural
    3. Tumors and brain swelling also have a mass effect on the brain.
    4. Stroke -- infarction or death of an area of the brain
    5. Head Injury that leads to internal swelling, bleeding, or hypoxia (depletion of oxygen)
    6. Seizures
  • Extracranial (outside the brain) and metabolic causes:

    1. Cardiac Arrest -- deprives the brain of oxygen
    2. Blood sugar variations -- Hypoglycemia or hyperglycemia
    3. End stage liver disease -- Ammonia build up affects the brain
    4. Kidney failure or uremia -- build up of toxic waste normally excreted by the kidneys may affect the brain
    5. Endocrine deficiencies -- disorders of hormone-producing glands, such as thyroid, adrenals, and pituitary
    6. Drug overdose -- alcohol, sedatives
    7. Diabetic Ketoacidosis -- build up of ketones may affect the brain
    8. Electrolyte imbalances
    9. Carbon Monoxide Poisoning
    10. Very low or high body temperatures -- hypo- or hyperthermia
    11. Electrocution -- accidental exposure to high voltage or lightning
    12. Lead Poisoning, pesticide (organophosphates) poisoning

  • A medical history of medications, diseases, past surgeries, injuries, psychiatric history, occupation, habits, social history, and recent travels are important in diagnosis -- family members may need to be contacted for a full history.
  • A physical examination from head to toe is done to assess the stage and severity of the coma.
  • The Glasgow Coma Scale (assigns a score) describes the response to stimuli. The parameters tested include the ability to open the eyes, response to pain (movements or motor response), the presence or absence of speech (verbal response), and its appropriateness. This scale is more useful if done serially to assess progress, rather than only once on admission.
  • Breathing patterns, pupil size (e.g., pinpoint in heroin-induced coma), neurological findings (e.g., if one side of the body is paralyzed, there is a structural brain lesion), abnormal posturing of limbs, and fruity Breath Odor (as in ketoacidosis) -- all of which may give clues to the cause of coma.
  • Labs include: 

  1. Blood chemistries -- liver and kidney functions, Electrolytes (including Magnesium and Calcium), glucose, Ammonia level, and toxicology screen 
  2. Complete blood count and differential 
  3.  Blood gas analysis
  4. Urine for glucose and ketones 
  5. May include a spinal tap

  • Radiology tests:
    1. CT scan or MRI of head
    2. Cerebral Angiography

  • See causes

  • Coma is an emergency
  • The first step is to support and stabilize the vital signs, such as blood pressure, breathing, and temperature.
  • Intravenous (IV) fluids are started immediately, and all patients receive Dextrose (glucose solution), Naloxone (antagonist to opiate drugs such as heroin) and Thiamine (B vitamin), unless contraindicated.
  • Oxygen is given to all patients in coma. Respiratory support using mechanical ventilation may be needed if the patient is not breathing.
  • Patient is transferred to an intensive care unit to be monitored.
  • Measures must be taken to prevent complications of prolonged immobility (e.g., Bed Sores, limb contractures, infections).
  • In patients who do not recover from coma, family members, physicians, psychologists, and social workers may need to meet and discuss "quality of life issues" (e.g., should the patient be resuscitated if the heart suddenly stops).
  • Family members and friends of the patient should ask the doctors they know for any new treatments or ongoing clinical trials.

  • See causes
  • Psychiatric illnesses such as:
    1. Catatonia
    2. Depression
    3. Conversion reactions






more about Coma


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