Coma (cont.)

Medical Author:

Benjamin Wedro, MD, FACEP, FAAEM

Benjamin Wedro, MD, FACEP, FAAEM

Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

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Medical Editor:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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In this Article

• What is a "coma"?
• What is the Glasgow Coma Scale?
• What are the causes of a coma?
• Trauma
• Bleeding (Hemorrhage)
• Epidural, subdural, and subarachnoid hemorrhages
• Tumors
• Swelling
• Infection
• Lack of oxygen
• Hypoglycemic coma
• Poisons
• How is coma assessed?
• What tests are there for coma?
• What is the outcome and prognosis for a patient in a coma?
• Induced Coma
• Patient Comments: Coma - Cause
• Coma Index

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 heartbeat and blood pressure)?
• Is the patient hypoglycemic? The blood sugar can be checked by a quick fingerstick bedside test and if it is low, glucose can be administered under the tongue or intravenously. Patients with diabetes may also have a Glucagon injection kit that can be administered to treat low blood sugar.
• 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, imagine a person sitting at a bar who falls down, hits his head and is in a 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 perhaps a diabetic medication reaction and the blood sugar was 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 Glasgow Coma Scale score will be documented; the deeper the coma, the lower the score. Please appreciate that a person with a "normal" Glasgow Coma Scale 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 determining if the coma is improving, worsening or remaining stable.