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Acute
coma
Definition

Unconsciousness , Disturbance of
consciousness

Degression of level of consciousness

Deep inhibitory state of higher
nervous activity
Mechanism

Consciousness
①
Level of awareness of brain
②
Sensation, Perception
Himself , Enviroment
③
Responsiveness
Inner need, External stimulation
④
Expressed
language, Body movement, Behavior

Composition of consciousness

Cognition

Contents ：
Orientation, Perceptivity, Attention,
Remembrance, Affection, Thinking and Behavior

Expressed ：
Language,Body movement and behavior

Controlled ：
Cerebral cortex
Waking state
Controlled
Ascending reticular activating system in
brainstem ( ARAS )
Function
Special sensory conduction →
Unspecial nerve corpuscle in thalamus →
All cerebral cortex
Etiology and pathology
 Disturbance
①
Cerebral cortex
②
Ascending reticular activating
system in brainstem or thalamus
Feature of Ascending
reticular activating system
①
Thin nerve fiber
②
Longer transmiting distance
③
More times for neurone to be exchange
④
Influenced easily by enviroment and drug
Clinical classification
Disturbance of consciousness in level
Coma, Confusion
Special kinds of disturbance of
consciousness
Dementia, lapsus memoriae
Clinical classification of unconsciousness
Somnolence
Stupor
Arousal
+
+
Orientation
+
Go with
examination
+
Reaction to
stimuli
Spontaneous
action
Brainstem
reflexes
Babinski
sign
Vital sign
Light coma Deep coma
-
-
-
-
-
-
+
+
+
-
+
+
+
-
+
+
+-
-
+
+
+-
-
stable
Stable
stable
unstable
Special group of disturbance of consciousness
Confusion
Delirium
Somnolence
+
+
Irritation
-
+
Orientation
+
-
Attenuation
-
-
Delusion
Illusion
+
+-
+
+
Insight
+
-
Change in
autonomic nerve
+
+
Glassgow coma scale
Eye
Verbal
Motor
Scores
Obeys commands
6
Orientated
Localises pain
5
confused
Withdraws from
pain
4
Eye opening to Inappropriate
words
speech
Flexion to pain
(Decorticate)
3
Incomprehe
Eye opening to
-nsible sounds
pain
Extension to pain
(Decerebrate)
2
No verbal
No eye opening
response
No motor
response
1
Eyes opening
spontaneously

Special groups of conscious disturbance
— coma vigil
1)
Open and close eyes
2)
Chew and swallow
3)
Sleep-wake cycles

Decorticate syndrome
1)
Arms flex ，leg straighten
2)
Higher muscular tension
3)
Babinski sign
4)
Cerebral cortex is damaged

Decerebrate syndrom
1)
Four limbs straighten
2)
Higher muscular tension
3)
Babinski sign
4)
All brain is damaged

Akinetic mutism
1)
Muscle relaxation，
2)
No babinski sign
3)
Ascending reticular activating system
in brainstem or thalamus is damaged
Differential diagnosis

Persistent vegetative state
1)
“Unconscious and unaware”
2)
Exhibit sleep-wake cycles
3)
Grinding teeth, swallowing, smiling,
shedding tears, grunting, moaning, or
screaming
4)
Heads and eyes can track moving objects or
turn towards a sound
5)
An impaired connectivity between the
brainstem, thalamus and the cortex
6)
The general brain activity in the cortex is
lower in the PVS state.
Brain death
Complete and irreversible cessation of brain
activity (cerebral, brain stem , cerebellum)

Criteria
1)
Deep coma
2)
No spontaneous respiration
3)
No response to pain, no cranial nerve
reflexes
4)
Spinal reflex may persist
5)
EEG: flat or isoelectric 24h
6)
Exclude for intoxication, hypothermia,
metabolic disturbance or persistent
vegetative state

Hysteria

Syncope
1.
Transient loss of consciousness and posture
2.
A global reduction in blood flow to the brain

Locked-in syndrome
A lesion of the ventral pons.
1)
Alert
2)
Unable to response with speech or facial or
limb movements
3)
Vertical eye movements and blinking
 Abulia
A lesion of both lobus frontalis
 Serious Apathy
 Stuporous state
 Stupor syndrom
A rough response ( like screaming ) to a
noxious stimulus
Etiology
 Central
nervous system diseases

Cerebrovascular disease

Cerebral thrombosis

Cerebral embolism

Cerebral hemorrhage

Subarachnoid hemorrhage
 Headtrauma

Seizure

Inflammation
Encephalitis, meningitis, cerebral abscess
 Tumor
 Hypoxia

Heart -- Cardiac output ↓
Heart failure, Asystole, tachycardia,
bradycardia

Lung -- pO2 ↓, pCO2↑, acidosis
COPD, pneumonia, pneumonedma
pulmonary infarction, drowing
 Liver--hepatic
coma
Serious hepatitis,hepatonecrosis
hepatic cirrhosis
 Kidney—Uremia
Acidosis, ion disturbance or cerebral edema
after dialysis

Metabolic abnormalities
Hypoglycemia, hyperglycemia,
Ketoacidosis, hyperosmosis，lactic acidosis
hyperthyroidism crisis，Addison‘s disease
sheehan syndrome

Electrolyte disturbances
Low sodium, low chlorine, water intoxication
 Intoxication

Drug：
Benzodiazepine, barbiturates,
antipsychotic drug

Insecticide：
Organophosphorus，pyrethroid
carbamate pesticide，weed killer
Other intoxicant
Alcohol, Carbon Monoxide,
Organic solvent, poisnous vapor
Physical examination

General examination

Temperature
T↑ ：Inflamation, central high fever
heat stroke
T↓ ：Shock, hypoglycaemia, Hypnotic
intoxication
 Arterial
pulse
p ↓：Sinus bradycardia, atrial ventricular
block(A-VB) ,intracranial hypertension
p↑：Hyperpyrexia, hyperthyreosis
congestive heart failure, shock
supraventricular tachycardia

Breath
Rhythm

Cheyne-Stokes breathing
---- A lesion of Cerebral hemishere

Central neuro-hyperventilation
---- A lesion of midbrain

Ataxia breathing
---- A lesion of bulbus medullae
Smell
---- Rotten apple, garlic, alcohol, amonia,
hepatic odor

Blood pressure
BP↑ ：hypertensive encephalopathy, CH
BP↓ ：shock

Skin and membrana mucosa
Jaundice, bleeding point, ecchymosis,
Sweat, cyanosis, flush

Cranal trauma
Raccon eyes, Battlesign，
leakage of cerebrospinal fluid

Meningeal irritation sign
Kernig sign or brudzinski sign

Examination in internal medicine
Heart, lung, liver, kidney, etc.

Neurologic check
 Eyes sign

Pupil
One dilatation：Cerebral hernia
Both dilatation：Atropine poisoning
Both diminution: Organophosphate，morphine
Hypnotic，hypoglycaemia
A lesion of brainstem
Eyeball
position
Fixation：

Divergence: cerebellum

Side-glance：

Lesion of side glance centre
（ cerebral hemisphere or pons ）
Fasciculus longitudinalis mediali
Eye ground
Bleeding
Vitreous hemorrhage
Angiosclerosis,
Papilledema

Pain recation
Locating
Decorticate rigidity ( thalamus or cerebral
hemisphere ),
Decerebrate rigidity (midbrain)
Assessment
Degree of coma
 Palsy sign
Hemiplegia, Babinski sign
 Brainstem function

Corneal reflex

Oculovestibular reflex

Oculocephalic reflex (Dull head test)
Auxiliary examination
• CT, MRI , EEG , examination of
cerebrospinal fluid
• Po2, Pco2, HCO3, BE , CoHb,
Hemiglobin, Choline esterase (CHE)

GPT,GOT, Blood ammonia , BUN Cr,
Ion, Blood glucose

Detecting intoxicant or product of
metabolism
Diagnosis
History+Physical sign + Auxiliary
examination
 Onset ：environment, process, time degree
of urgency, motivation, etc.
Main
Age,
symptom and concomitant symptom
season, past history
 Treatment

Symptomatic treatment
1)
Monitor: ECG, BP, Consciousness, pupil
pulse, respiration , etc.
2)
Open respiratory tract
3)
Balance water , electrolytes and acidbase.
4)
Relieve and prevent cerebral edema
20% manital, complexglycerine,
furosemide , 50%Glucose, Albumin, etc.
5)
Protection for cerebral function

Radical scavenger：barbiturate, VC,VE


Opiate receptor blocking pharmacon: Narcon
Ca2+ receptor blocking pharmacon
Nimodipine , Flunarizine , etc.
6)
Hypothermy, Hibernotherapy:
Tympanic temperature: 33~35℃

Etiological treatment

Prevent complication

Aspirated pneumonia,

Urinary system infection,

Bedsore,

Disturbance of Water-Electrolyte （Hyponatremia）

Acid- base balance