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COMA Is a sleeplike state in which the patient makes no purposeful response to the environment and from which he or she cannot be aroused. Coma results from lesions that affect either the reticular activating system or both hemispheres since these are the brain regions that maintain consciousness APPROACH TO MANAGEMENT Ensure patency of the airway and adequacy of ventilation and circulation Insert an intravenous catheter and withdraw blood for laboratory studies Begin an intravenous infusion and administer dextrose, thiamine, and naloxone 1-Every comatose patient should be given 25 g of dextrose intravenously, typically as 50 mL of a 50% dextrose solution, to treat possible hypoglycemic coma. 2-administration of dextrose alone may precipitate or worsen Wernicke's encephalopathy in thiamine-deficient patients, all comatose patients should also receive 100 mg of thiamine by the intravenous route. 3-To treat possible opiate overdose, the opiate antagonist naloxone, intravenously, should also be administered . Institute treatment for seizures, if present Persistent or recurrent seizures in a comatose patient should be considered to represent status epilepticus and treated accordingly History 1- A sudden onset of coma suggests a vascular origin 2- Rapid progression from hemispheric signs, is characteristic of intracerebral hemorrhage 3- A more protracted course leading to coma (days to a week or more) is seen with tumor, abscess, or chronic subdural hematoma 4- Coma preceded by a confusional state or agitated delirium, without lateralizing signs or symptoms, is probably due to a metabolic derangement Lateralizing (Focal ) Signs 1- Assymmetry of pupils. 2- Squint 3- Assymmetry of the face 4- Gaze palsy 5- Assymmetry of motor response, reflexes & plantar response Diseases that cause no focal or lateralizing neurologic signs A. Intoxications: B. Metabolic disturbances: anoxia, diabetic acidosis, uremia, hepatic failure, C. Severe systemic infections D. Circulatory collapse (shock) E. Postseizure states and convulsive F. Hypertensive encephalopathy G. Hyperthermia and hypothermia. state, H. Concussion I. Acute hydrocephalus Diseases that cause focal brainstem or lateralizing cerebral signs A. Hemispheral hemorrhage or massive infarction B. Brainstem infarction C. Brain abscess D. Epidural and subdural hemorrhage E. Brain tumor F. Cerebellar and pontine hemorrhage. G. Miscellaneous: cortical vein thrombosis, viral encephalitis In these cases no focal sing present as at involve all of brain A. Subarachnoid hemorrhage from ruptured aneurysm. B. Acute bacterial meningitis C. Some forms of viral encephalitis General Physical Examination A. SIGNS OF TRAUMA B. BLOOD PRESSURE Elevation of blood pressure may also be a consequence of the process causing the coma, as in intracerebral or subarachnoid hemorrhage C. TEMPERATURE Hypothermia can occur in coma caused by ethanol or sedative drug intoxication, and hypoglycemia. Coma with hyperthermia is seen in heat stroke, status epilepticus, malignant hyperthermia . E- Breathing 1- Pattern : Air hunger indicate metabolic cause as aspirin over dose or renal failure or metabolic ketoacidosis Cheyne- stokes indicate intracranial or cardiac cause 2- Smell : Drugs Alcohol Acetone smell metabolic ketoacidosis Fetor hepaticus hepatitis Abnormal gait skeletal abnormalities, usually characterised by pain producing Gaits that do not fit either pattern may be due to psychiatric disorders and are usually incompatible with any anatomical or physiological deficit . Pyramidal gait Upper motor neuron (pyramidal) lesions Foot drop lower motor neuron lesion Myopathic gait proximal muscle weakness, usually caused by muscle disease Ataxic gait lesions in the cerebellum , vestibular apparatus or peripheral nerves Sensory ataxia Impairment of joint position sense Apraxic gait higher cerebral dysfunction Extrapyramidal gait in Parkinson disease and other extrapyramidal diseases INVOLUNTARY MOVEMENTS Rest tremor pathognomonic of Parkinson disease . It is characteristically pill rolling Physiological tremor most common type of action tremor It is common in normal subjects and exaggeration occurs in anxiety and in Fatigue, Toxins , Alcohol withdrawal Essential tremor The condition is often inherited , Alcohol often suppresses it, distinct from a physiological tremor, although resembling it superficially Intention tremor occurs in cerebellar disease , characterised by oscillation at the end of a movement Asterixis (flapping tremor) seen in metabolic disturbances, result of intermittent failure of the parietal mechanisms required to maintain a posture. Causes of asterixis : Renal failure Liver failure, Hypercapnia, Acute focal parietal or thalamic lesion Chorea, athetosis, ballism These are due to disturbance of balance of activity in the basal ganglia Chorea : Jerky, smallamplitude, purposeless involuntary movements causes : Hereditary , Cerebral birth injury , Cerebral trauma , Drugs , Endocrine disease, Infective inflammatory Hemiballismus: More dramatic ballistic flying violent movements of the limbs usually occur unilaterally in vascular lesions of the subthalamic structures. Athetosis : Slower writhing movements of the limbs . These are often combined with chorea (and have a similar list of causes) and are then termed 'choreoathetoid' movements Dystonia sustained involuntary contraction that causes abnormal posture or movement. It may be generalised in various diseases of the basal ganglia or may be focal or segmental, segmental dystonias can be treated by the administration of botulinum toxin to a few of the responsible muscles Tics Tics are repetitive semi-purposeful movements such as blinking , distinguished from other involuntary movements by the ability of the patient to suppress their occurrence, at least for a short time.