Coma (cont.)
How is coma assessed?
When a patient presents in coma, diagnosis and treatment begin
simultaneously. Initial treatment is aimed at addressing immediate
life-threatening issues:
- Are the ABCs intact? Is the patient's airway open? Are they breathing? Do
they have good circulation (a heart beat and blood pressure)?
- Is the patient hypoglycemic? The blood sugar is checked by a quick
fingerstick bedside test and if it is low, glucose is administered.
- Did the patient ingest a narcotic?
Naloxone (Narcan) may be
given intravenously to reverse an overdose situation.
History remains the important key to the diagnosis. Since the patient cannot
be the source of information, questions are asked of family, friends, bystanders,
and rescue personnel. For example, a person sitting at a bar fell down, hit his
head and is in coma. While it might be easy to jump to the conclusion that he
was intoxicated, fell, and bled in his brain, other scenarios need to be
considered. Did he have a heart attack, did he suffer a stroke, or was this
a diabetic medication reaction and the blood sugar is low.
Once the patient has been stabilized with acceptable vital signs, physical
examination will include a complete neurologic assessment. From head to toe,
this may include examination of the eyes, pupils, face movements to assess
cranial nerves including facial movement and gag reflex, extremity movement and
reaction to stimulation, tendon reflexes and other testing of spinal cord
function. There is special attention paid to symmetry in the neurology exam,
since lack of movement or response on one side of the body may be caused by
bleeding inside the skull or by stroke. General examination surveys the skin for
cuts, scrapes, wounds, etc.
The GCS score will be documented; the deeper the coma, the lower the score.
Please appreciate that a person with a "normal" GCS of 15 still can be in coma.
Once the initial screening physical examination complete, a more detailed exam
will likely occur to include the lungs, the heart, and the abdomen. Repeated
neurologic assessment is key to monitoring the status of the patient and decide if
the coma is lightening or getting worse.
Next: What tests are there for coma? »
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