Coma (Coma)

What is Coma (Coma)?

A coma is a state of deep unconsciousness or unresponsiveness, showing that the brain isn’t working effectively. This can be due to an issue within the brain itself or even a result of a bodywide metabolic issue. The causes can be as simple as metabolic problems that can easily be fixed, or as serious as life-threatening masses. Doctors often need to perform both resuscitation and diagnostic processes at the same time.

A coma typically doesn’t last forever, but can remain for an indefinite period. In this state, both the brain’s ability to alert and arouse and the person’s awareness and consciousness are affected. Syncope, on the other hand, is a short loss of consciousness followed by a quick return to alertness.

Various forms of impaired mental status can range from mild confusion to more severe conditions such as lethargy, stupor, and obtundation. Although these terms are clearly mentioned in medical literature, they can often be misused, creating confusion. Lethargy basically means a person has less attention and slight drop in wakefulness. Obtundation relates to a dull awareness and reduced response to surroundings. Stupor refers to a deeper unconscious state where a person can only be momentarily roused with strong stimulation. Doctors should essentially assess a patient’s reaction to stimuli and accurately describe that reaction to avoid using confusing terms.

Ratings systems for comas can be a simplified way to monitor a patient’s consciousness level over time and help identify any trends.

The first task of the health professional is to stabilize the patient in coma and treat any reversible causes, such as low blood sugar. Afterwards, more assessments are made to find out the probable cause of the coma, or to decide whether it’s due to a structural or nonstructural brain problem.

What Causes Coma (Coma)?

Coma refers to a state where the brain stops functioning properly. This situation can be brought about by a multitude of reasons, some stemming from issues that affect the structure of the brain, while others don’t involve structural changes but impairment in the normal functioning of the brain.

Issues related to metabolism or infections can affect the entire brain leading to a coma. Everyday situations like low or high blood sugar levels, excessive consumption of alcohol, overuse of medication or illegal drugs are commonplace causes behind a coma. Hypoglycemia (low blood sugar) and widespread infections represent the major causes of non-structural comas. Other less frequent culprits behind metabolic comas can include liver-related brain disease, abnormal levels of sodium or calcium in the blood, hormonal imbalances, and more.

Brain infections like meningitis or encephalitis, though not very commonplace, can also lead to a coma and are crucial to identify.

Structural brain diseases are another major cause behind comas. These can include brain bleed following a head trauma, spontaneous bleeding in the brain, clot in the brain veins, tumors, a sudden build-up of fluid in the brain, an increase in the internal brain pressure, oxygen shortage in the brain, or strokes in the brainstem.

In some cases, severe epileptic fits can progress to a trance-like state or an imperceptible form, where the person is unresponsive with little or no body movement, termed as ‘transformed’ or ‘end-stage’ status epileptics. With the increased use of EEG (a test that measures brainwave patterns) in intensive care units, patients who are not exhibiting general seizures but have severely abnormal EEG results, indicating non-apparent status epileptics, are now being recognized.

Risk Factors and Frequency for Coma (Coma)

Coma is a condition that is frequently encountered in emergency rooms, but it’s tough to figure out exactly how often it happens. This is due to the fact that few studies have been done on patients who arrive at the hospital in a coma. There are also multiple ways to describe and code this condition, making it tricky to keep track of cases. In medical records, different healthcare professionals may assess the condition differently. And, sometimes, the cause of the coma is treated before the patient even gets to the hospital, which adds another layer of complexity to tracking the number of cases.

In a recent study of over 1000 patients who came to the hospital in a coma (excluding cases caused by brain injuries or heart attacks), it was found that these types of patients made up 0.4% of all emergency department patients. The main diagnoses of these comatose patients fell into three categories:

• Brain damage like bleeding or tumors (39%)
• Brain disorders without apparent injury, mainly epilepsy (25%)
• Conditions that affected the brain indirectly, like sepsis, substance poisoning, or metabolic disorders (36%)

About one-third of these patients had more than one condition that could explain their coma.

Signs and Symptoms of Coma (Coma)

A paradox exists when trying to understand why a patient is in a coma: you need their history to uncover the reasons for their unconscious state, but their unconscious state makes it difficult to gather this history. However, once the patient is stable, try to get information from emergency service (EMS) providers, family members, co-workers, or bystanders.

When examining a patient in a coma, it’s crucial to address the basics of emergency care – including the patient’s airway, breathing, and circulation. Other examinations should focus on identifying potential signs of injury from a general physical check. The initial neurological examination should consider the patient’s response to pain, motor functions, whether they can open their eyes, and any verbal output. Examining the cranial nerves, including movement of the eyes, and reflexes like pupillary, corneal, cough, and gag, is also essential. If the patient is showing abnormal posturing or one pupil is dilated, it could indicate a problem such as compression of a nerve from a mass, otherwise known as uncal herniation syndrome. If no localized findings are discovered during examination, coma might be due to metabolic, infectious, or toxic causes.

The neurological examination is often documented and can be roughly quantified using various scoring systems, such as the Glasgow Coma Scale or the FOUR score. These brief rating scales are handy for sequentially monitoring the patient, albeit with some limitations.

The Glasgow Coma Scale measures:

• Eye response: from spontaneous eye-opening (4 points) to no eye-opening (1 point)
• Motor response: from obeying commands (6 points) to no motor response (1 point)
• Verbal response: from being oriented (5 points) to no verbal response (1 point)

The FOUR Score measures:

• Eye response: from eye-tracking or blinking on command (4 points) to eyelids remaining closed with pain (0 points)
• Motor response: from making a thumbs-up, fist, or peace sign (4 points) to no response to pain (0 points)
• Brainstem reflexes: from pupil and corneal reflexes present (4 points) to absent pupil, corneal and cough reflex (0 points)
• Respiration: from not intubated with regular breathing pattern (4 points) to breaths at ventilator rate or below (0 points)

Testing for Coma (Coma)

When first assessing a patient who is unconscious, doctors prioritize checking the patient’s airway, breathing, and circulation, often referred to as the A, B, C’s. There could be many reasons why someone might become unconscious, from infections to metabolic issues. If the initial assessment does not indicate a clear cause, more tests will be needed.

These might include lab tests to measure levels of different substances in the blood and tests to spot drugs or other toxins. Doctors usually check for things like electrolytes and blood gases right away. In some cases, they might also run tests for drugs or other harmful substances in the body.

As they gain more information about the patient’s condition, the doctors may also order brain scans to look for signs of bleeding, swelling, or other structural issues. These scans can be done using CT or MRI machines. Sometimes, they may do vascular imaging to check if the blood vessels in the brain are blocked.

Doctors will use all this information to figure out the most likely cause of the unconsciousness, which will then guide their decisions about treatment.

If the patient has recently had a major convulsion or seizure that is affecting their mental state, doctors may perform an EEG. This is a test that tracks brain activity and can be crucial since seizures can continue with minimal physical movement.

Deciding which tests to conduct often involves going through a checklist to determine if there is a need for advanced imaging or lab tests.

Treatment Options for Coma (Coma)

For all patients showing signs of confusion or impaired thinking, it’s recommended to check their blood sugar levels or provide them with glucose. It’s also advised to consider use of Naloxone, a medication that reverses the effects of opioids, in patients who have signs of opioid overdose like slow breathing, small pupils, or altered mental status. If none of these treatable conditions are present, further examination should be carried out. Simply put, the best way to cure a coma is to treat the health issues leading to it.

Doctors will often order multiple brain imaging tests if medical history, physical examination, and initial laboratory tests are unable to identify a clear treatment plan.

Patients at risk of inadequate nutrition, such as those with alcohol dependency, those who’ve had weight loss surgery, or those with long-term conditions that limit nutrient absorption, should receive Thiamine. However, the routine use of a so-called “coma cocktail,” a mix of drugs sometimes used in the treatment of coma, is not recommended.

To manage the condition, it’s crucial to ensure an adequate blood supply to the brain by maintaining the mean arterial pressure and avoiding low blood pressure. Continual supportive care, including safeguarding the airway and monitoring blood pressure, is also required. If signs or imaging suggest that pressure within the skull is increasing, the use of high concentration salt solutions may need to be considered and discussed with specialists.

What else can Coma (Coma) be?

There are other conditions that could seem very similar to coma. One key example is the “locked-in syndrome”. In this condition, patients can’t speak or move their limbs despite usually having their eyes open. This often happens due to a lack of blood flow or bleeding in a part of the brain called the pons. However, patients’ mental faculties are often not impaired, meaning that they’re still aware of and conscious of their surroundings. They can’t communicate this because the parts of the brain responsible for movement are damaged. Most of the time, the only responses you might see from these individuals are eye blinks or vertical eye movements. Even if they seem unresponsive, it’s best to assume they understand what’s being said around them.

There’s a recent term for a state akin to a “minimally conscious state”, which manifests as appearing unresponsive but with sporadic evidence of awareness. If observed for a longer duration, these patients can occasionally show signs of alertness such as following basic instructions, tracking objects with their gaze, or other responsive behaviors.

Fake unresponsiveness is usually short-lived and with careful observation and examination, occasional responsiveness or alertness may be observed. Tests involving the nerves in our skull would show normal results, including the caloric testing (used to assess responsiveness in patients). A sudden loud noise may cause the person to startle, indicating alertness. If there’s any doubt, performing a caloric test and demonstrating nystagmus (a rapid involuntary movement of the eyes) is a good indicator of alertness.

List of common causes of coma include:

• Brain damage due to lack of oxygen
• Stroke
• Bleeding in the brain, either spontaneously or due to trauma
• Brain tumors
• Brain damage due to high blood pressure
• Low blood sugar
• Brain damage due to a medical disorder affecting the body’s chemicals or hormones
• An underactive thyroid gland condition called Myxedema
• Severe, continuous seizures known as Status epilepticus
• Brain damage due to toxic substances

What to expect with Coma (Coma)

Patients who fall into a coma due to reversible causes, such as low blood sugar, can often be sent home after the appropriate treatment is given and it’s ensured that they’ll be safe at home. However, those who remain in a coma need to be admitted to a hospital where they can be continuously monitored, received necessary support, and get proper treatment for the cause of the coma. The cause of the coma also determines which hospital department they will be admitted to.

Patients in a coma due to trauma require constant monitoring and might need treatment for brain swelling or clot, along with supportive care to prevent further injury. Judging how these patients might fare in future can be tough and often becomes clear only after observing them for a while. Patients who end up in a coma after a cardiac arrest fare significantly better these days, thanks to the use of therapeutic cooling techniques. However, we must wait for a few days before we can accurately predict how this group of patients will do.

The prospects for patients who fall into a non-traumatic coma (a coma not caused by physical trauma) hinges largely on the cause of the coma and the person’s level of consciousness when admitted. In a study done at a single hospital on patients with non-traumatic coma, they found that more than a quarter of them died in the hospital and the overall death rate over two years was 43%. Less than 15% of patients died from poison related comas, while almost 90% of patients with cancer-related comas died. They also discovered that a lower coma score, which measures the level of consciousness, when the patients were admitted was associated with a higher death rate in the hospital.

Possible Complications When Diagnosed with Coma (Coma)

Treatment for a coma targets any identifiable causes. It’s also crucial to provide care to prevent further brain injury. This care could include advanced support for breathing and heart function. Tools to monitor and control high pressure inside the skull may be necessary. Basic care, like looking after the bladder, checking the skin, and taking actions to prevent bed sores, is also important.

Preventing Coma (Coma)

Just like with any health problem, it’s always better to prevent illnesses rather than treat them later. Some situations that could result in a coma might be preventable if intervention measures are taken earlier. For example, patients with uncontrolled diabetes could benefit from careful monitoring and proper education to prevent the progression to a coma. Similarly, individuals who are at risk of drug overdoses or illegal drug use could also have interventions. Given the widespread issue of opioid abuse, studies are showing that timely counseling and support with medication can actually help to reduce the chances of future overdoses.