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Assessing Coma and Management

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🧠 Coma Management Guide

⚠️ If the cause of coma is uncertain (e.g. CT negative), always consider giving the **CAND bundle**: 💉 Cefotaxime (meningitis cover), 💊 Aciclovir (HSV encephalitis), 💉 Naloxone (opiates), 🍬 Dextrose ± Pabrinex (thiamine, prevent Wernicke’s).
This covers the major reversible causes until further information is available.

🛠️ Coma Management Overview
🔄 Initial assessment: ABC, high-flow O₂, recovery position. If GCS < 9, seek anaesthetic review and prepare for intubation. 🖥️ Early CT head (and C-spine if trauma). Exclude SDH, EDH, ICH, tumour. 🧠 If CT shows bleed or mass → urgent neurosurgery referral. 🧩 If CT is normal → think metabolic, infective, toxic, endocrine causes: 💊 Opiates: Pinpoint pupils, low GCS → IV Naloxone 0.4 mg, repeat to max 2 mg. 🍬 Hypoglycaemia: IM Glucagon 1 mg and/or IV Dextrose (200 ml 20% or 50 ml 50%). 🦠 Meningitis: IV Cefotaxime immediately. 🧬 HSV encephalitis: IV Aciclovir 10 mg/kg q8h. 🧪 Endocrine: Suspected Addisonian crisis → Hydrocortisone 100 mg IV stat. 🌡️ Thyroid crisis: Consider IV T3/T4 for myxoedema coma (bradycardia, hypothermia). 🧲 Seizure / NCSE: Lorazepam IV, consider Keppra; EEG if uncertain. 🦟 Cerebral malaria: Travel history? → IV Quinine, blood films. ⬆️ Raised ICP: Intubate + hyperventilate (target pCO₂ 28–32 mmHg). IV Mannitol boluses if appropriate. Definitive neurosurgery (EVD, decompression, clot evacuation).

🛠️ Coma Management Overview

🔄 Initial assessment: ABC, high-flow O₂, recovery position. If GCS < 9, seek anaesthetic review and prepare for intubation.
🖥️ Early CT head (and C-spine if trauma). Exclude SDH, EDH, ICH, tumour.
🧠 If CT shows bleed or mass → urgent neurosurgery referral.
🧩 If CT is normal → think metabolic, infective, toxic, endocrine causes:

💊 Opiates: Pinpoint pupils, low GCS → IV Naloxone 0.4 mg, repeat to max 2 mg.
🍬 Hypoglycaemia: IM Glucagon 1 mg and/or IV Dextrose (200 ml 20% or 50 ml 50%).
🦠 Meningitis: IV Cefotaxime immediately.
🧬 HSV encephalitis: IV Aciclovir 10 mg/kg q8h.
🧪 Endocrine: Suspected Addisonian crisis → Hydrocortisone 100 mg IV stat.
🌡️ Thyroid crisis: Consider IV T3/T4 for myxoedema coma (bradycardia, hypothermia).
🧲 Seizure / NCSE: Lorazepam IV, consider Keppra; EEG if uncertain.
🦟 Cerebral malaria: Travel history? → IV Quinine, blood films.

⬆️ Raised ICP:
- Intubate + hyperventilate (target pCO₂ 28–32 mmHg).
- IV Mannitol boluses if appropriate.
- Definitive neurosurgery (EVD, decompression, clot evacuation).

🛌 Recovery Position

📏 Assessment of Coma: GCS & Pupils

📄 Download GCS Chart

🧠 Pathophysiology of Coma (ARAS)

Consciousness requires intact Ascending Reticular Activating System (ARAS) + cortex.
ARAS = brainstem nuclei → thalamus → cortex.
Coma occurs with ↑ ICP, bilateral cortical/thalamic damage, or brainstem dysfunction.
Pupils give localising clues: 🔴 Bilateral dilated, fixed → herniation/brainstem failure. 🔵 Pinpoint → pons or opioids. ⚖️ Unequal → structural lesion compressing CN III.

🧩 Consciousness depends on ARAS (midbrain/pons) + both cerebral hemispheres. Structural lesions or diffuse metabolic insults can both produce coma.

🧪 Differential Diagnosis: CT & Glucose First

Cause	Clues	Management
🍬 Hypoglycaemia	Low CBG	IV Dextrose
💊 Opiate toxicity	Pinpoint pupils	IV Naloxone
🧠 Stroke	Focal neurology	CT head, stroke pathway
⚡ Post-ictal	History of seizure	Recovery position, treat status
🦠 Meningitis/Encephalitis	Fever, neck stiffness	Cefotaxime + Aciclovir
☠️ CO poisoning	Exposure, headache, cherry-red skin	100% O₂ ± hyperbaric
🤕 Head injury	History of trauma	CT head/C-spine
💧 Hyponatraemia	Na <115, seizures	Hypertonic saline
🧬 Sepsis	Fever, shock	IV Tazocin + Gentamicin
📟 NCSE	Unresponsive, subtle eye movements	EEG, Lorazepam
💥 SDH/EDH	Head trauma	Neurosurgery + Mannitol
🦟 Cerebral malaria	Travel history	IV Quinine

⚡ Pupils in Coma

Pupil Type	Description	Causes
Normal	3–4 mm, reactive	Metabolic causes
Thalamic	~2 mm, reactive	Thalamic compression
Fixed dilated	>7 mm, unreactive	Herniation, CN III compression
Midsized fixed	~5 mm, unreactive	Midbrain lesion
Pinpoint	1–1.5 mm, minimal reaction	Pons, opioids, organophosphates
Asymmetric	Anisocoria	Structural lesion, CN III palsy

🚨 Signs of Trauma

🐼 Raccoon eyes (periorbital bruising).
🎧 Battle’s sign (mastoid bruising).
🩸 Haemotympanum.
💧 CSF rhinorrhoea/otorrhoea (confirm with β-2 transferrin).
👆 Palpable depressed skull fracture.

📊 Pathophysiologic Patterns

Feature	Supratentorial	Subtentorial	Diffuse/Metabolic
Pupils	Normal or dilated with herniation	Midsized (midbrain), pinpoint (pons)	Normal/reactive; pinpoint (opiates); dilated (anticholinergics)
Eye movements	May show gaze preference	Abnormal adduction/abduction	Usually preserved unless sedated
Motor	Often asymmetric	Asymmetric (uni) or symmetric (bi)	Usually symmetric

📚 Teaching Commentary

Coma is a syndrome, not a diagnosis. Always think structural vs metabolic. 🔍 Pupils are the fastest localising sign: normal = metabolic, abnormal = structural. 🇬🇧 In UK practice, juniors should remember: “CAND for coma if CT is normal” → Cefotaxime, Aciclovir, Naloxone, Dextrose + Pabrinex. This covers the major reversible killers until more is known. GCS < 8 = intubate. Always immobilise the neck if trauma suspected.

References

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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