CASES OF COMA

CASES OF COMA

Definitions:
Decreased levels of alertness, eyes closed, there is no any response to pain stimuli, sometimes accompanied by extension or flexion posture at both extremities

Cause
• supratentorial lesions
- Infarction, hemorrhage, tumor, abscess, trauma
• Lesions subtentorial
- Compression lesions (hemorrhage, infarction, aneurysm, tumor abscess cerebellum)
- Destructive lesions (hemorrhage, infarction, migraine, demyelinisasi)
• diffuse lesions or metabolic
• Psychiatry (conversion, depression, catatonic stupor)

Pathophysiology
• Any condition that causes lesions or disorders at ARAS system, thalamus, and cerebral cortex will cause commas.

Clinical Picture
• Patients do not respond eyes, voice, and movement when given strong pain stimuli.
• Sometimes patients have decorticate or decerebrate posture.

Basic Diagnostics
1. Anamnesis = find information:
- Onset
- Course of the disease
- History of disease
- History of treatment or medication that is consumed
- Injury or trauma at this time,
- Seizure-like activity,
- Other accompanying symptoms (such as hot, past medical problems).

2. General Examination:
- Search for signs of trauma (such as Battle's sig or bruising in the 

   mastoid area; leakage of cerebrospinal fluid)
- Evidence of seizures (tongue biting, urinary incontinence)

Examination

Doll's eye:
There is no cervical injury
Normal (+): the opposite of head motion
Caloric testing:
Intact tympanic membrane, the position of 30 degrees
Cold water - eye deviation
pupil:
Midposition - Anisokor
Pin Point - Reactivity pupil down
fixed dilated

Preliminary Therapeutic Coma

Examination	Management
Airway, Breathing, Circulation	Secure the airway If required to do intubation Check the oxygen saturation, give oxygen if needed Measure blood pressure and pulse Attach cardiac monitor
Began doing laboratory tests	Check glucose levels using the finger test Check arterial blood gas Check the electrolytes, complete blood count, calcium, magnesium, ammonia, drug levels, PT, PTT Consider skrening toxin materials

Supportive Therapy

Thiamine 50-100 mg iv Naloxone (Narcan) 1 ampoule iv D50 iv glucose (at least 25 ml)

Anamnesis

Collect the basis of clinical history  If signs and symptoms lead to meningitis (loss of consciousness, heat, meningismus), consider empiric antibiotic therapy and did a lumbar puncture if there are no contraindications  If signs and symptoms lead to herniation (progressive loss of consciousness, decorticate or decerebrate posture, n.III unilateral paralysis), do efforts to reduce intracranial pressure  If there is evidence of complaints lead to seizures, give loading anti-seizure

CT scan	CT scan of the head without contrast Check the cervical vertebrae injury
Lumbar Puncture	Perform a lumbar puncture to rule out subarachnoid hemorrhage or infection (with a record of the results of the CT scan did not reveal any herniation or other cause of coma)
Other	Give specific therapy according to the results of existing metabolic abnormalities, CT scan or lumbar puncture Perform anamnesis further and more complete