Comatose Patient

Clinical description

The comatose patient requires prompt attention. Coma is a state of deep unconsciousness for a prolonged or indefinite period of time.

Signs and symptoms

History Elicited from relatives or the ambulance workers: onset of coma, condition in which patient was found, fever, convulsions, any pertinent chronic medical illnesses (i.e. diabetes or asthma), alcohol and/or substance abuse, poisoning, suicide note, etc. Minimal OB history includes parity, GA, and history of PVB.

Exam/Investigations Temperature, vitals/O2 saturation, pallor, jaundice, cyanosis, neck stiffness, Glasgow Coma Scale* (GCS), neurological exam (pupillary reaction, deep tendon reflexes), abdominal exam for peritonitis and/or haemoperitoneum (to assess for uterine rupture or abruptio placentae), check breath for alcohol and/or ketones

Treatment

• Call for help
• Airway: ventilate if patient is cyanotic
• Breathing: intubate if no spontaneous breathing
• Circulation (check pulse and BP): resuscitate if signs of shock
• Insert urinary catheter, monitor urine output, and check UPT
• Send blood for glucose, FBC, U&Es, and Malaria
• Send blood and urine for culture
• Start IV line
• Treat with 50 ml of 50% dextrose unless glucose is confirmed as normal
• If organophosphate poisoning suspected, then treat with atropine 0.6-2.4 mg IV every 15 min until normal

PR, dilatation of pupils, etc. Obtain physician consultation.

• Admit patient to HDU (high dependency unit)
• Monitor VS, GCS, and pupillary reaction

 If poisoning, then monitor every 30 min until normal

• Perform LP if no contraindication
• Consider Head CT if not improvement within 24 hours or neurological exam suggests possible

stroke

• Take full history when possible
• Nursing care
• Feeding via nasogastric tube
• 2 hourly turnings

*Glasgow Coma Scale (range: 3-15) 1 2 3 4 5 6 Does not Opens eyes in response Opens eyes in Opens eyes Eye N/A N/A open eyes to painful stimuli response to voice spontaneously Oriented, Makes no Incomprehensible Utters inappropriate Confused, Verbal converses N/A sounds sounds words disoriented normally Abnormal flexion to Extension to painful Flexion / Localizes Makes no painful stimuli Obeys Motor stimuli (decerebrate Withdrawal to painful movements (decorticate commands response) painful stimuli stimuli response)