Level of consciousness:

Fully conscious Drowsy easily arousable by touch or noise, alertness persist for short period Stupor arousable only by vigorous stimulation Coma not arousable by any form of stimulus

Anatomy and physiology of coma:

Reticular activating system (RAS) required to maintain alertness and coherence of thought

Causes of coma: - lesion that damage RAS in upper midbrain or its projections - destruction of large portions of both cerebral hemisphere - suppression of reticulocerebral functions by drugs, toxins or metabolic derangements

Causes of coma:
1. Metabolic disturbance - drug / toxic - Diabetes mellitus hypoglycemia - ketoacidosis - hyperosmolar coma - hyponatremia - uremia - hepatic failure - respiratory failure - hypothermia - hypothyroidism 2. Trauma - cerebral contusion - extradural hematoma - subdural hematoma

3. Cerebrovascular disease - subarachnoid hemorrhage - intracerebral hemorrhage - brain stem infarction/hemorrhage - cerebral venous sinus thrombosis 4. Infections - Meningitis - Encephalitis - Cerebral abscess - General sepsis 5. Others - Epilepsy - Brain tumor

Diabetic ketoacidosis
Complication of Type 1 DM Precipitating factors: Inadequate insulin administration Infection (pneumonia/UTI/sepsis) Drugs (cocaine) Pregnancy

Symptoms: -polyuria, thirst -Abdominal pain -Nausea, vomiting -Shortness of breath

Signs: -dehydration -hypotension -tachycardia -Kussmaul breathing -smell of acetone -hypothermia -confusion, drowsiness, coma (10%)

Hyperglycemic hyperosmolar non-ketotic diabetic coma

complication of Type 2 DM due to sustained hyperglycemic diuresis prototypical patient is an elderly individual with type 2 DM, with a several-week history of polyuria, weight loss, and diminished oral intake that culminates in mental confusion, lethargy, or coma signs: dehydration, hypotension, tachycardia to differentiate from DKA: i. evolution is over days ii. No acetone odour on breath iii. No Kussmaul respiration iv. No abdominal pain

Hypoglycemia
due to treatment with insulin and oral hypoglycemic drugs Symptoms: i. Autonomic sweating - trembling - pounding heart ii. Neuroglycopenic-confusion, drowsiness, convulsion, coma -loss of fine motor skill, incoordination -hunger -anxiety

Features

Hypoglycemic coma

DKA

History Onset Symptoms Signs

No food, too much insulin, unaccustomed exercise In good previous health Of hypoglycemia Full pulse Normal or raised BP Moist skin and tongue Shallow or normal breathing

Too little or no insulin, infection ill health for several days Of dehydration Weak pulse Low BP Dry skin and tongue Kussmaul breathing with acetone smell

Hepatic failure / hepatic encephalopathy

Liver fails nitrogenous waste(ammonia) builds up passes to brain where astrocytes clear( glutamate to glutamine) fluid into cells Grade: I- altered mood, sleep disturbance II- increasing drowsiness, confusion, slurred speech III- stupor, restless IV- coma Other signs: -Fetor hepaticus -Asterixis -Constructional apraxia -signs of chronic liver failure if acute-on-chronic liver disease cerebral edema excess glutamine causes shift of

Myxedema coma
complication of hypothyroidism C/F: long standing history of hypothyroidism, usually elder patients precipitated by infections, hypoxia, hypercapnia, cardiac failure Looks of hypothyroid (pallor, coarse brittle diminished hair, puffy lids) hypothermia hyporeflexia convulsion may have episode of psychosis with delusions and hallucinations myxedema madness before losing consciousness observe for goiter or any thyroidectomy scars

Drugs / poisons
OP poison diarrhea, urinary incontinence, miosis, bradycardia, sweating, emesis, lacrimation ; muscle twitching, fasciculations, diminished respiratory effort; confusion, convulsion, coma

Opiates miosis, bradycardia, hypothermia, respiratory depression, coma

Barbiturate, benzodiazepines drowsiness, midposition/dilated pupil, ataxia, nystagmus, minor hypotension, respiratory depression, confusion, coma

Hypothermia
Causes: -Exposure -Alcoholic, barbiturate, sedative -Hypoglycemia -Peripheral circulatory failure -Extreme hypothyroidism Hypothermia itself causes coma only when temperature is <31

Seizures
Generalized tonic-clonic seizures -Altered consciousness at onset. -Tonic phase:patient becomes cyanosed, does not breathe, heart rate changes and may even stop, pupils dilated. -Clonic phase: rhythmic jerks appear. Tongue may be bitten, urinary or bowel incontinence may occur. -In post ictal phase- patient may passed into coma also due to exhaustion of energy reserves or locally toxic molecules by-product of seizures. Not arousable, may be totally flaccid, plantar response extensor

Status epilepticus
-2 fits occur without recovery of consciousness in between

-A single fit last longer than 30 minutes with or without loss of consciousness( some define as 5 minutes)

Epidural hematoma
-Etiology: head injury

-Typical lucid interval pattern: as ICP rises, patient will have increasing headache, vomiting, confusion and comatose.

If bleeding continues, ipsilateral pupil dilates, coma deepens, bilateral limb weakness

Breathing becomes deep, irregular (brainstem compression)

Subdural hematoma
-Etiology: - Trauma (often forgotten) - elderly (brain atrophy causing bridging vein atrophy) - falls ( epileptics, alcoholics) -Symptoms: - fluctuating level of consciousness - insidious physical or intellectual slowing - headache -Signs: - of increased intracranial tension

Subarachnoid hemorrhage
Causes: -Aneurysm at circle of Willis -Arterio-venous malformation -Trauma -Mycotic aneurysm -Anticoagulant

C/F: -Sudden onset of occipital headache, vomiting, seizures, stiff neck, coma. -Focal neurological deficits (may suggest site of aneurysm). Eg. 3rd nerve palsy in posterior communicating artery aneurysm

Intracerebral hemorrhage
Commonly occurs secondary to hypertension where penetrating branches undergo degeneration.
Putamen is the most common site for hypertensive hemorrhage, adjacent internal capsule is usually damaged Contralateral hemiparesis When hemorrhages are large, signs of upper brainstem compression appear. Coma ensues, accompanied by deep, irregular, or intermittent respiration, a dilated and fixed ipsilateral pupil, and decerebrate rigidity

Pontine hemorrhages- deep coma with quadriplegia usually occurs over a few minutes. Decerebrate rigidity and pinpoint pupils that react to light Impairment of doll's-head reflex or by irrigation of the ears with ice water

Meningitis
-Pyogenic meningitis headache, drowsiness, fever, vomiting, neck stiffness, Kernigs sign, Brudzinskis sign In severe case, may present in comatose condition.

-Viral meningitis usually benign in course unless associated with encephalitis.

Encephalitis
-suspect encephalitis whenever patient presents with infectious prodrome: - fever - rash - lymphadenopathy - meningeal signs

together with encephalopathic behaviour: - confusion - disorientation - poor coordination of movements - focal neurological signs. Eg. Hemiparesis, aphasia

-Herpes simplex encephalitis important to suspect as treatable * Treat before exact cause is know

Thank you