Coma

• Coma: abnormally deep state unconsciousness from which pt cannot be aroused by external stimuli

  • Mechanisms that produce: structural & toxic metabolic
• Structural causes:

  • Intracranial bleeding
  • Head trauma
  • Brain tumor or other space-occupying lesions
• Metabolic causes:

  • Anoxia
  • Hypoglycemia
  • Diabetic Ketoacidosis
  • Thiamine deficiency
  • Kidney & liver failure
  • Postictal phase of seizure
• Drugs:

  • Barbiturates
  • Narcotics
  • Hallucinogens
  • Depressants (alcohol)
• Cardiovascular System:

  • HTN encephalopathy
  • Shock

  Dysrhythmias

  • Stroke
• Respiratory System:

  • COPD
  • Toxic inhalation (CO poisoning)

  Infection:

  • Meningitis
  • Sepsis
• A - acidosis or alcohol

  E - epilepsy

  I - infection

  O - overdose

  U - uremia

  T - trauma

  I - insulin

  P - psychosis

  S - stroke
• Structural (tumor, abscess): depress consciousness by destroying or encroaching on ascending reticular activating system in brainstem

  • Focal (asymmetrical) neurological signs
  • Sudden onset
  • Unresponsive or asymmetrical pupillary response
  • Follows a progressive pattern of deteriorartion caused by focal pressure or compression
  • Rule: lesions affect ascending reticular activating system by inc. ICP & herniation
• Toxic metabolic: involve the presence of circulating toxins or metabolites or lack of metabolic substrate (oxygen, glucose)

  • Neurological findings often symmetrical
  • Slow in onset
  • Preserved pupillary responses
• Assessment & Management:

  • Airway maintenance & ventilatory support w/ O2
  • With unconscious pt w/ no gag reflex should be intubated
  • Establish IV lin
  • Monitor ECG
  • If alcohol is suspected: thiamine 100mg IV
  • If hypoglycemia:
  • Adult: 25g (50mL D50) IV
  • Newborn: 5mL/kg D10 slowly (1mL/kg D50 mixed w/ 4mL/kg NS)
  • Less than 13 yo: 2mL/kg D25 (1mL/kg D50 mixed with 1mL/kg NS)
  • 13 yo or older: 1mL/kg D50
  • If pt does not respond to glucose or thiamine Naloxone (narcan) to rule out narcotic depression:
  • Adult: 2mg IV/IM/SC/ET/IN
  • Pediatric:
  • <5 or <20kg: 0.1mg/kg IV/IM/SC/ET
  • >5 or >20kg: 2mg IV/IM/SC/ET
• • If Pt still comatose state, transport pt in lateral recumbent position (if not contraindicated)
  • Monitor airway & have suction ready