Presentation and buzz words:
State of profound unconsciousness characterized by the absence of wakefulness and a lack of meaningful response to external stimuli.
Often due to reversible causes.
Tips for physical exam:
Serial GCS. Any interval changes?
Formal neurologic exam should still be done on comatose patients. Never say "unable to assess."
Note their vital signs, particularly oxygen requirement
Brainstem reflexes:
Elicit pupillary reflex and size with penlight
Elicit corneal reflex by lightly brushing eyelashes, introducing a saline flush, or cotton swab
Elicit gag and cough reflexes with suctioning device. If you have never done this before, please ask for help from RN or RT.
Attempt cranial nerve exam. Any nystagmus, asymmetry, involuntary movements?
Any spontaneous movements or response to pain? As in GCS, note if they are able to follow commands, localize painful stimuli, or show any signs of posturing.
Attempt strength exam. Even if they do not appear following verbal commands, mirror the movements you are asking.
Test deep tendon reflexes and Babinski.
Interventions:
What did we do to them?
Intubated? Trach?
Any surgeries?
What sedation/analgesia could be contributing?
What does imaging show?
Diagnose:
How did this happen? Trauma, massive stroke, malignancy, infection? What underlying cause have we yet to address?
Differential diagnosis:
Traumatic brain injury
Stroke
Intracranial hemorrhage
Metabolic disturbances (e.g., hypoglycemia, hepatic encephalopathy)
Drug overdose or intoxication
Infection (e.g., meningitis, encephalitis)
Structural lesions (e.g., brain tumors)
Seizures or status epilepticus
Hypoxic-ischemic injury
Order CBC, CMP, glucose, ABG, toxicology screen
Neuroimaging, EEG
Lumbar puncture if infection is suspected.
Daily management:
q1h neuro checks
Normothermia, normoglycemia, euvolemia
Bowel reg, DVT prophylaxis. If intubated, PPI.
Daily SBTs: even if not ready for ETT weaning, SBTs are good exercise for the patient.
Nutritional support via enteral or parenteral routes.
Consult nutrition for tube feeds.
Consult SLP for formal swallow studies.
Consult PT/OT to prevent complications like contractures and muscle wasting.
Spiritual care availability and family meetings for joint decision making.
Prognostication:
Calculate Acute Physiology and Chronic Health Evaluation (APACHE) II score and Sequential Organ Failure Assessment (SOFA) score to estimate ICU mortality risk.
Complications:
"ICU fever" is a risk for any patient with prolonged hospital stay. Make sure to monitor their vital signs and tylenol requirement as well as respiratory secretions.
Brain death is not synonymous with coma, but they can occur on the same spectrum, depending on the underlying cause. Link to brain death page.