Coma: Diagnosis and emergency management

2021-08-04 06:00 PM

Coma is an emergency, prompt action is needed to preserve life and brain function, often with blood tests and brain CT scans to determine the cause.

Coma: Diagnosis and emergency management

Coma diagnosis and treatment

Coma is a state of unresponsiveness or decreased response of the patient to stimuli. This is a true disturbance of consciousness and awakening, and normal stimulation does not restore the patient's state of consciousness.

It can be caused by a variety of problems - a head injury, strokes, brain tumors, drug or alcohol intoxication, or even an underlying disease, like diabetes or an infection.

Diagnosing a coma

Definite diagnosis

Clinically, coma manifests as:

Loss of consciousness.

And the state of losing consciousness.

The patient's level of consciousness was assessed using the Glasgow scale.

The Glasgow coma score (GCS score) was determined by the sum of the scores of the three criteria above, the highest score being 15 and the lowest score being 3, as follows: GCS score = E + M + V

E - Eye-opening point

Conscious (natural) eye-opening: 4 points.

Eye-opening response to commands: 3 points.

Eye-opening response to pain: 2 points.

No eyes open: 1 point.

V - Speech response score

Directed response: 5 points.

Messy answer: 4 points.

Inappropriate answer: 3 points.

Difficulty speaking: 2 points.

No answer: 1 point.

M - Motor response score

Follow orders (follow orders): 6 points.

Localized response to pain: 5 points.

Withdrawal when causing pain: 4 points.

Decorticate posturing: 3 points.

Decerebrate posturing: 2 points.

No response to pain: 1 point.

Mild: GCS score ≥ 13; Average: 9 ≤ GCS ≤ 12; Heavy: GCS 8

* If there is endotracheal intubation: there are 5 points of speech; seems to want to say 3 points; do not respond/score.

Differential diagnosis

The state of immobility

The patient is awake, the eyeball is oriented and closed when threatened.

Locked-in syndrome

Paralysis of limbs, bilateral facial paralysis, paralysis of lips, tongue, throat, glottis, transverse eye movement.

The rest: move the eye up, down, open the eyes, can still be contacted.

This means that the patient is awake and conscious.

Dysfunction, hysteria, psychosis

Think of hysteria when: let the patient lie down, lift the patient's hand in front of the face, release the hand to let it fall, the patient will have a reflex to hold the hand.

The eyeball that avoids bright images is usually bent downwards, the pupils are normal and reflect light well.

Diagnosis of common causes of coma

Coma in cerebrovascular diseases

Includes cerebral infarction, cerebral hemorrhage, and subarachnoid hemorrhage.

The clinical picture is coma + focal paralysis + a cardiovascular disease.

Coma related to infectious disease

Meningitis.

Not come.

Cerebral venous thrombosis.

Malignant fever.

Coma associated with convulsions

Epilepsy state.

Convulsions due to hypoglycemia.

Seizures due to eclampsia.

Convulsions associated with mass-occupying tumors are seen in brain tumors and brain abscesses.

Coma related to metabolic disease

Complications of diabetes mellitus: hyperosmolar coma, ketoacidosis coma, hypoglycemic coma.

Liver coma.

Coma due to uremia syndrome.

Coma due to severe electrolyte disturbances: hyponatremia, hypokalemia, hypercalcemia.

Coma in endocrine diseases: hypothyroidism, adrenal insufficiency, polyglandular insufficiency syndrome.

Coma related to toxic pathology

The most common is sleeping pill poisoning.

The opium group and the types of the medulla.

Other poisonings such as organophosphorus poisoning, alcohol poisoning, co...

Coma in traumatic brain injury

In relation to the trauma, a coma may appear shortly after the injury (brain contusion) or coma after a period from the time of injury (awake interval) often with a subdural hematoma-type lesion.

Necessary tests

Basic tests

Liver function, kidney function, electrolytes, blood sugar, blood calcium, complete blood count, urinalysis. Consider blood and urine toxicology screening.

Computed tomography and/or cranial magnetic resonance imaging

To evaluate structural brain damage.

Other diagnostic tests

Consider lumbar puncture in patients with fever, headache, or high risk of CNS infection.

EEG recording to rule out seizures or confirm the diagnosis of metabolic and infectious encephalopathy.

Coma treatment

Position: comatose patients should be placed in a position of 20° - 30° head elevation, neck straight (if hypotension is not present) or a safe side position if there is a risk of aspiration.

In cases of the coma of unknown cause, immediate consideration should be given to:

+ Hypertonic glucose combined with vitamin B1 injection (prevention of hypoglycemia in alcohol drinkers).

Flumagenil (benzodiazepine poisoning).

+ Naloxone (opioid drug overdose).

Control respiratory function

Open the airway: suck sputum, remove foreign objects from the mouth and respiratory tract, put in a safe lying position to avoid tongue drop, choking. If necessary, insert an oral canun.

Provide oxygen: give oxygen to the patient through a nose mask or mask, closely monitor the respiratory status, breathing rate, capillary oxygen saturation (Sp02).

Endotracheal intubation: if the patient does not breathe oxygen, the patient is in a deep coma (Glasgow < 8 points), sputum accumulation is abundant.

Artificial ventilation: indicated for all patients after intubation with respiratory failure that does not improve or patients with signs of increased intracranial pressure, patients struggling, agitated needing antiepileptic drugs. God.

Circulatory function control

If the patient has hypertension: it is necessary to use antihypertensive drugs appropriately, maintaining blood pressure close to the baseline.

If the patient has hypotension, cardiovascular collapse, shock: ensure hemodynamic control if the volume is reduced, need rehydration or blood transfusion if indicated, use vasopressors when the volume is fully compensated.

Against cerebral edema and increased intracranial pressure

When the patient has clinical manifestations of cerebral edema, increased intracranial pressure, the patient should be treated immediately. Ideally, intracranial pressure should be measured and monitored.

Treatment measures include hyperventilation, head position 20° - 30°, infusion of hypertonic solutions: mannitol, 3% sodium chloride.

Anti-convulsant

It is possible to give diazepam 10mg intravenously, phenobarbital intramuscularly, propofol intravenous infusion, needing good control of convulsions and good respiratory control.

Search for the cause of convulsions to treat: metabolic disorders, water and electrolyte disorders, the cause of drug poisoning causing seizures.

Blood purification and detoxification

Usually applied to patients due to poisoning with sleeping pills such as Gardenal, other poisonings can use a specific antidote.

Hypotonic infusion hypoglycemia.

Overdose of opiate preparations using an antagonist (naloxone).

Other treatments

Treatment of water, electrolyte disorders, and severe metabolic acidosis.

Treatment of infectious causes of meningitis, encephalitis.

Urinary catheterization, anti-ulcer, patient turning, therapeutic exercise.

Anti-stagnation, anti-inflammatory venous thrombosis (use low molecular weight heparin if there are no contraindications).

Eye protection: eye patch, avoid dry eyes.

Treat hyperthermia or hypothermia.

Ensure adequate energy: choose the appropriate feeding route: oral, nasogastric tube, parenteral nutrition.

Consider surgical indications (neurosurgery specialist consultation).

Traumatic brain injury with epidural, subdural hematoma.

Cerebral vascular malformations, brain tumors, brain abscesses.

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