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Assessing Coma and Management

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If the cause of coma is uncertain (e.g., CT scan is negative), consider giving Cefotaxime, Aciclovir, Pabrinex (Thiamine B1), and Naloxone until further information is available.

Coma Management
Initial assessment: ABC, administer O₂, place in the recovery position, and seek anaesthetic review if GCS < 9. Perform early CT head and exclude neck fractures. Address surgical causes: If subdural hematoma (SDH), epidural hematoma (EDH), intracerebral hemorrhage (ICH), or a tumor is suspected, refer to neurosurgery. Consider medical causes, especially if the CT scan is normal: Opiate toxicity: Small pupils, low GCS. Administer IV Naloxone 400 mcg (0.4 mg), repeatable up to 2 mg if needed. Hypoglycaemia: Administer IM Glucagon 1 mg and/or 200 ml 20% or 50 ml 50% Dextrose IV or equivalent. Suspected Meningitis: Administer Cefotaxime IV. Suspected HSV Encephalitis: Aciclovir 10 mg/kg IV every 8 hours. Artery of Percheron stroke: Consider Aspirin if low GCS. Endocrine causes: If adrenal insufficiency is suspected, administer Hydrocortisone 100 mg IV stat. Sepsis: Administer Tazocin and Gentamicin. Thyroid crisis: IV T3/T4 for suspected myxoedema coma (low temperature and bradycardia). Seizure: Consider postictal state. If non-convulsive status is suspected, assess eye movements. Consider Lorazepam/Keppra IV and consult neurologist. Large MCA stroke: Consider mechanical thrombectomy if indicated. Malignant MCA stroke: Consider decompressive hemicraniectomy. Cerebellar stroke: Consider decompressive surgery or shunting for hydrocephalus. Cerebral malaria: Administer IV Quinine and send blood films if there is a relevant travel history. Raised Intracranial Pressure (ICP): Intubate and ventilate to lower pCO₂ to 28-32 mmHg. Administer Mannitol IV boluses if appropriate. Refer for definitive surgical intervention (e.g., evacuation of hematoma, decompressive hemicraniectomy, or external ventricular drain for hydrocephalus).

Coma Management

Initial assessment: ABC, administer O₂, place in the recovery position, and seek anaesthetic review if GCS < 9. Perform early CT head and exclude neck fractures.
Address surgical causes: If subdural hematoma (SDH), epidural hematoma (EDH), intracerebral hemorrhage (ICH), or a tumor is suspected, refer to neurosurgery.
Consider medical causes, especially if the CT scan is normal:

Opiate toxicity: Small pupils, low GCS. Administer IV Naloxone 400 mcg (0.4 mg), repeatable up to 2 mg if needed.
Hypoglycaemia: Administer IM Glucagon 1 mg and/or 200 ml 20% or 50 ml 50% Dextrose IV or equivalent.
Suspected Meningitis: Administer Cefotaxime IV.
Suspected HSV Encephalitis: Aciclovir 10 mg/kg IV every 8 hours.
Artery of Percheron stroke: Consider Aspirin if low GCS.
Endocrine causes: If adrenal insufficiency is suspected, administer Hydrocortisone 100 mg IV stat.
Sepsis: Administer Tazocin and Gentamicin.
Thyroid crisis: IV T3/T4 for suspected myxoedema coma (low temperature and bradycardia).
Seizure: Consider postictal state. If non-convulsive status is suspected, assess eye movements. Consider Lorazepam/Keppra IV and consult neurologist.
Large MCA stroke: Consider mechanical thrombectomy if indicated.
Malignant MCA stroke: Consider decompressive hemicraniectomy.
Cerebellar stroke: Consider decompressive surgery or shunting for hydrocephalus.
Cerebral malaria: Administer IV Quinine and send blood films if there is a relevant travel history.

Raised Intracranial Pressure (ICP):

Intubate and ventilate to lower pCO₂ to 28-32 mmHg.
Administer Mannitol IV boluses if appropriate.
Refer for definitive surgical intervention (e.g., evacuation of hematoma, decompressive hemicraniectomy, or external ventricular drain for hydrocephalus).

Recovery Position

Assessment of Coma: Use Glasgow Coma Scale (GCS) and Examine Pupils

Download GCS Chart

Pathophysiology of Coma: Ascending Reticular Activating System (ARAS)

Consciousness is the awareness of the environment and self, maintained by the ARAS.
The ARAS connects brainstem nuclei with the cerebral cortex, involving structures like the locus coeruleus, dorsal raphe, hypothalamus, and basal forebrain.
Impairment occurs due to elevated intracranial pressure (ICP) or bilateral cortical or thalamic damage, leading to a loss of consciousness.
Brainstem compression can cause pupillary changes: bilateral mydriasis with unresponsive pupils suggests brainstem damage, while pontine damage can cause pinpoint pupils.

Differential Diagnosis: CT Head and Capillary Blood Glucose (CBG) Are Key

Cause	Management
Hypoglycaemia	Check CBG and give IV Glucose.
Opiate toxicity	Small pupils. Administer Naloxone. Remove opiate patches.
Stroke	CT head to confirm, protect airway, and initiate appropriate stroke care.
Post Seizure	ABC, recovery position, treat further seizures as status epilepticus if indicated.
Encephalitis/Meningitis	Administer Aciclovir and Cefotaxime. Obtain imaging and consider lumbar puncture if safe.
Carbon Monoxide	Measure COHb, provide 100% O₂, consider hyperbaric therapy.
Head Injury	Stabilize neck, obtain CT head and cervical spine.
Hyponatraemia	Consider hypertonic saline if Na < 115 mmol/L and seizures.
Sepsis	Administer IV broad-spectrum antibiotics.
Non-convulsive Status	Consider EEG and IV Lorazepam if non-convulsive status is suspected.
Subdural/Epidural Hematoma	Administer IV Mannitol, consult neurosurgery for decompression.
Cerebral Malaria	Consider in recent travel history; administer IV Quinine.

General Measures

Check CBG immediately; if uncertain, give glucose.
Establish IV access, obtain bloods, and perform a thorough physical assessment.
Check COHb levels if carbon monoxide exposure is suspected.
Perform top-to-toe examination, including removal of opiate patches.
Obtain CT head +/- neck imaging to rule out injuries or structural abnormalities.
Assess pupils for signs of herniation or toxic/metabolic causes:

Unilateral dilation suggests ipsilateral brain compression.
Small pupils suggest opioids; large pupils may indicate stimulants or severe intracranial pressure.

If CT is normal but diagnosis remains unclear, administer Naloxone, glucose, Cefotaxime, Aciclovir, and Pabrinex.
Consider EEG for non-convulsive status epilepticus.
If GCS < 9, intubation is needed to protect the airway. Consider HDU/ICU care.

References

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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