Dr.

Nelly Gang
Emergency Department
Sheba Medical Center

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 Definition
It is a state of reduced alertness and
responsiveness from which the patient
cannot be aroused
Consciousness = Awareness and Arousal

Regulated by cortical Maintained by

areas within the cerebral Reticular activating
hemispheres System (RAS)
Glasgow coma
scale (GCS)
Eye opening
Spontaneous 4
To voice 3
To pain 2
None 1
Verbal response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible words 2
None 1
Motor response
Obeys commands 6
Localizes pain 5
Withdraws from pain 4
Flexion (decorticate) 3
Extension (decerebrate) 2
None 1
Scoring guide

Minimum score 3

Maximum score 15

Mild brain injury 13 or higher

Moderate brain injury 9 to 12

Severe brain injury 8 or lower

 GCS (cont.)
Advantages: a simple scoring system
assessment of separate
verbal, motor, and
eye-opening function

Disadvantages: lack of acknowledgement

of hemiparesis or the
focal motor signs
lack of testing of higher
cognitive function
 Pathophysiology
Deficiency of substrates needed for neuronal function
(hypoglycemia, hyponatremia, hypoxia)

The presence of certain substances that disrupt the

functioning of neurons (drugs, alcohol, ammonia, ketons,
CO2)

Electrical derangements caused by seizures

Primary CNS causes: hemorrhage, SOL, infection. The

function of either the brainstem and/or both must be
impaired for unresponsiveness
 Pathophysiology of altered
mental status

Altered mental status

Differential diagnosis

Substrate Environmental
Deficiencies Toxic/Metabolic
Structural Psychogenic Hypothermia
Glucose Intoxication
Hyperthermia
Oxygen

Traumatic Atraumatic
 Causes of Coma
Infection
Toxic
Metabolic
Hypoxemia
Hypercarbia
Cerebrovascular
CNS
Psychiatric
Traumatic Causes of Coma

Subdural hematoma
Epidural hematoma
Intraparenchymal hematoma
Subarachnoid hemorrhage
Diffuse axonal injury
Intacerebral pressure (ICP)
Maintaining cerebral perfusion pressure
(CCP) = MAP-ICP
Monro-Kellie principle: volume within the
skull is fixed and contains three
components: brain, blood, CSF
Increase in the amount (cerebral edema,
hematoma, hydrocephalus) or the addition
(tumor) results in increased ICP.
 Herniation syndromes
Result from increased ICP
Lead to brainstem compression
Hypertension, bradycardia, respiratory
irregularities (Cushing triad)
Uncal, central, cerebellar
ICP result from SOL (tumor, hematoma),
trauma, infection, severe metabolic
derangement
Uncal herniation syndrome

Medial temporal lobe shifts to compress

the upper brainstem progressive
drowsiness unresponsiveness

Ipsilateral pupil dilatation, loss of

extraocular movements (III cranial n.)

Ipsilateral hemiparesis
Decorticate:
Extension of lower ext., flexion of the upper
ext.
The lesion is above the midbrain
Better prognosis than decerebration

Decerebrate:
Extension of both lower and upper ext.
The lesion is at level of midbrain or
diencephalon
Approach to the Patient With
Coma
Primary survey
Immediate
interventions
Diagnostic studies
Supportive care
Secondary survey
 Approach to the Patient With
Coma (cont)

ABCs
Intravenous access, oxygen therapy
Accu-check / glucose / thiamine
Cardiac monitoring with pulse oximetry
Cervical spine precautions
Naloxone
Intubation?
Approach to the Patient With
Coma (cont)

History:
Trauma
Drug use
Medical history: seizures, diabetes,
cirrhosis, depression
Precomatose activity and behavior:
headache, confusion, vomiting
Sudden versus gradual onset of coma
Approach to the Patient With
Coma (cont)

Focused physical examination:

systemic trauma, drug use.

Evidence of trauma elsewhere on the

body is presumptive of head trauma in the
comatose patient.
 Systemic Trauma
Raccoon eyes
Battles sign
Hemotympanum
CSF rhinorrhea/
otorrhea
Subconjunctival
hemorrhage
Approach to the Patient With
Coma (cont)
Neurological examination:
Level of consciousness: GCS
Cranial nerve examination (pupillary response) level
of brainstem dysf. Pupillary abnormalities (CN II
afferent, CN III efferent) (especially unilateral) early
indicator of herniation.
Large unresponsive pupils brain death,
antycholinergics
Pin point pupils Pons, opiates
Corneal: V afferent, VII efferent -pons
GAG: IX, X -medulla
Approach to the Patient With
Coma (cont)

Motor examination:
Presence of movement, asymmetry . Are they
involuntary, reflexive, purposeful. (noxious
stimulation)
Purposeful: localization
Reflexive: stereotypical responses, occur in
the absence of cortical input
Decerebrate posturing, decorticate posturing
Diagnostic Studies in the Coma
Patient

EKG / cardiac monitoring

ABG with carboxyhemoglobin
CBC, electrolytes, Ca, Mg
Drug screen, ETOH
Urinalysis
Radiologic studies : CT Brain / MRI Brain (hemorrhage,
SOL, cerebral edema)
Consider LP (if no ICP), liver, thyroid and adrenal
studies
EEG
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Pitfalls in the Management of
Patients with Altered Mental
Status

Assuming ETOH is responsible

Not considering hypoglycemia
Failure to consider C-spine injury
Nonaggressive airway management
Inadequate exam
Not recognizing toxidromes
Delays in imaging the brain