COMA

Conf. Dr. Rodica Blaa

 Coma
(C-I)
Consciousness (Con) is a set of neural process that allow an
individual to perceive, comprehend and act on internal and external
environments.
Consciousness is envisioned in two parts:
Arousal describes the degree of which the individual appeas to
be able to interact with external and internal environments.
Waking and sleeping are common examples of two different
states of arousal.
Awareness reflects the depth and content of aroused state and
implies that the patient is not alert but is cognizant of self and
surroundings (awareness is dependent on arousal).
Awareness does not imply any specificity for modality of
stimulation (external auditory or internal thirst).
Attention depends on awareness and implies the ability to
respond to particular types of stimuli (modality-specific).
 C II
Gradation of Con.
Stuporous refers to a condition in which the patients is less alert
than usual but can be stimulated into responding.
Obnubilation is clouding of Con.
Obtunadation is a condition of mild to moderately reduced Con,
the subjects being rousable with verbal or slightly painful stimuli
but tending to sip back into sleep after the stimuli cease (this
eyes-closed state is not EEG-sleep).
Lethargy (old expression) is a state of deep and prolonged
unconsciousness, resembling profound slumber, from which the
person can be aroused but into which he immediately relapses
The comatose patient lies with eyes closed and does not make an
attempt to avoid noxious stimuli (such person may display various
posturing decorticate or decerebrate).
Vegetative state is a condition in which patient is aroused but not
aware.
 C III

Definition.
Coma is a state of unconsciousness, lasting more than six hours
in which a person: a) has inability to be aroused; b) cannot be
awaked; c) fails to respond normally to painful stimuli, light and
sound; d) lack a normal sleep-wake cycle; e) does not initiate
voluntary actions.
Examination.
The examination of patient with altered consciousness being
by ensuring that patients vital signs (blood pressure, pulse,
respiration, oxygen saturation, blood basic biochemistry) are
adequate to support brain function.
 C IV
Glasgow Coma Scale (GCS).
GCS was devised to provide a simple, reliable and reproducible
method of assessment of conscious state.
GCS has become a universally accepted scale for neurological
observation, prognostication and grading severity.
GCS comprise three tests: eye, verbal, motor responses.
The three values separately as well as their sum are
considered.
The lowest possible GCS (the sum) is 3 (deep coma).
The highest is 15 (fully awake).
Severe brain injury = 8.
Moderate brain injury = 9-12.
Minor brain injury = 13.
Many clinicians regard a maximum GCS of 8 as cutoff for coma.
 CV

GCS (cont 1)

Response Score
Eye opening
Spontaneous4
Opens to verbal command.3
Opens to pain, not applied to face2
None..1
 C VI

GCS (cont 2)
Response Score
Best verbal response
Oriented.......................5
Confused conversation, able to answer question..........4
Inappropriate words, words discernible.......... 3
Incomprehensible speech..2
None.......1
 C VII

GCS (cont 3)

Response Score
Best motor response
Obeys command for movement6
Localizes painful stimuli..5
Flexion/withdrawal to painful stimuli4
Abnormal (spastic) flexion decorticate response3
Abnormal (rigid) extension decerebrate response.2
None..1
 C VIII
Respiratory patterns.
Normal breathing.
Cheyne-Stokes: periodic increase and decrease of rate and depth,
followed by an expiratory pause and then a repeated pattern.
Hyperventilation: the state of breathing faster or deeper than
normal, causing excessive expulsion of circulating CO2 (CO2
tension is falling below normal 35-45 mmHg) and sometimes
respiratory alkalosis.
Cluster breathing: periods of rapid irregular breathing separated
by periods of apnea, without the crescendo/decrescendo pattern
or regularity of the latter.
Apneustic breathing: deep inspiration followed by breath
holding, then long slow expiration at a rate of 6 breath/min.
Ataxic (Biots) breathing: irregular and disorganized breating.
 C IX
Pupil examination.
Equal-sized and reactive pupils in a comatose patient indicate a
metabolic or toxic cause.
Unequal-sized pupils: a) imply a structural lesion of the brain or
cranial nerves; b) one caveat is that direct ocular trauma may
produce mydriasis; c) a pupil that dilates after a cerebral insult is
indicative of increasing intracranial pressure on ipsilateral
oculomotor nerve resulting from uncal herniation through the
tentorial hiatus; d) dilated nonreactive pupils from the time of an
injury imply irreparable brain damage or bilateral optic nerve
injury; e) the Horners syndrome implies disruption of the
sympathetic nervous system input to the pupil.
Bilateral pinpoint pupils occur with pontine lesions.
Bilateral fixed and dilated pupils (7 to 10 mm) occurs with
medullary injury.
Bilateral nonreactive pupils at the mid position (4 to 6 mm)
occurs with an extensive midbrain lesion.
 CX

Deviation of the ocular axes.

Bilateral conjugate deviation: a) frontal lobe lesion = the eyes
look the side of the lesion; b) pontine lesion = the eyes look away
from the side of the lesion; c) downward deviation = thalamic or
midbrain pretectal lesions.
Unilateral outward deviation with dilated pupil = nerve III palsy.
Unilateral inward deviation = nerve VI palsy.
Skew deviation = dorsal midbrain lesion.
 C XI
Spontaneous eyes movements.
Occular bobbing with rapid downward movements of the eyes
and a slow return occurs in pontine lesions.
Random conjugate eyes movements are nonspecific for lesion
location.
in the periodic alternating gaze (ping-pong gaze) the deviate
side to side with frequency of 3 to 5 per second and pause of 2 to 3
seconds in each direction = bilateral cerebral dysfunction.
Internuclear ophthalmoplegia.
Internuclear ophthalmoplegia is caused by a lesion of the medial
longitudinal fasciculus = the eye on the side of the lesion does not
adduct on spontaneous or reflex-induced eyes movement.
 C XII

Reflex eyes movements.

Oculocephalic reflex (dolls eye reflex): a) in the comatose
patient with intact brain stem and cranial nerves, the reflex is
preserved and the eyes move in the opposite direction when the
head is turned laterally or the neck flexed and extended ( the
conjugate eye movement is contraversive); b) when the brain stem
is damaged, the reflex is lost and the eyes follow the head
movement
 C XIII

Decorticate posturing.
Decorticate posturing is abnormal flexion of the upper limbs
(adduction of the arm and slow flexion of the elbow, wrist and
fingers) and extensor posturing of the lower limbs (extension,
internal rotation and plantar flexion).
It occurs with large cortical or subcortical lesions.
The corticospinal tract is interrupted above the level of midbrain.
 C XIV

Decerebrate posturing.
Decerebrate posturing is abnormal extension of upper and lower
limbs with internally rotated legs, variability clenched teeth and
opisthotonus.
There is said to be disinhibition of the vestibulospinal tract and
pontine reticular formation by removal of inhibition of the
medullary reticular formation = the transection is at the
intercollicular level between the red nuclei and vestibular nuclei in
the classical lesion.
It occurs with brain stem injury at the level of midbrain or below.