Coma Pearls

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.