Major depression, bipolar illness, are recognizable illnesses which present with alterations of global mental state. This is a feature of coma, in a broad sense. It needs to be assessed, as one would assess a coma state.

Severe attacks of major depression and bipolar illness should receive an emergency medical examination, searching for the possible causes of coma and confusional states.

This article discusses a general approach to diagnosis and initial emergency stabilization, and therapy of patients presenting with alterations in their global mental state, that is, either in the level of consciousness, coma in the broad sense, or in the ability to maintain a coherent and sustained stream of consciousness while awake, confusional states with or without agitation. Coma and confusion are two overlapping manifestations of failure of certain global, or state-dependent, brain functions (i.e., the systems for the maintenance of arousal and global attention) 46with many possible underlying causes. Because many of these causes present an immediate threat of death or severe disability, it is important for the physician to take an organized approach to the rapid assessment, stabilization, and treatment of such patients”. COMA AND CONFUSIONAL STATES: EMERGENCY DIAGNOSIS AND MANAGEMENT. Steven K. Feske. VOLUME 16, ISSUE 2, P237-256, MAY 01, 1998. DOI: Metrics

Management of coma

  1. 1. Why coma management?• Common medical emergency 3-5%• Large proportion of comatose patient recover• Untreated coma may lead to further brain damage 
  2. 2. Check vital signs• Respiration• Pulse, BP,• temperature
  3. 3. Emergency treatment• Maintain ventilation oxygenation• Maintain circulation• Control seizure• Reduce icp• Maintain temperature• Control hypoglycemia 
  4. 4. Maintain ventilation• Insert oral airway• Clean oropharyngeal secretion• Insert cuffed endotracheal tube if apnea, hypoventilation or liable to aspirate• Mechanical ventilation if apnea or raised intracranial pressure 
  5. 5. Draw Blood for• Start venous line• Complete blood count, MP, B.sugar• Blood urea, s. creatinine, s.electrolyte• Blood gases, ALT, AST• Give 25% 100ml glucose with 100mg of thiamine 
  6. 6. Maintain circulation• If hypotenstion ( <90mmHg systolic) – Replace fluid: • Saline if hyperglycemia or suspected stroke, diabetes • Dextrose saline or isolyte if undiagnosed – Vasopressor if low systolic pressure inspite of fluid• Hypertension: Betablocker, Nitroglycerine or Nitropruside 
  7. 7. Control Seizure• Inj Lorazepam 4mg or Midazolam 5mg IV slowly• Inj Diazepam 10-20mg iv slowly• Inj Phenytoin 15-20mg/Kg 50mg/min IV• Inj Phenobarb 15-20mg/Kg 50mg/min IV• Inj Sodium valproate 200-400mg IV 
  8. 8. Reduce intracranial pressure• Inj Mannitol 20% 1gm/kg IV fast• Hyperventilatin to bring pCO2 25-30mmHg 
  9. 9. Maintain Temperature• Hperthermia: tapid sponging, largectil,• Hypothermia: heating blanket 
  10. 10. Is it Coma ?• Posture: loss of erect posture• Eye closed: sleep like state• Lack of responsive ness 
  11. 11. Psychogenic coma• Holds eye tight, resist opening• Fixed stare, quick blink• Normal pupil• Normal oculocephalic• Normal oculovestibular• Normal posture, breathing, bp,pulse 
  12. 12. Spectrum of Coma• Psychogenic unresponsiveness• Acute confusional state• Locked in syndrome• Akinetic mutism• Persistent vegetative state• Brain death 
  13. 13. What causes coma?Metabolic:- Structural:- – Ischemic hypoxic – Supratentorial bilateral – Hypoglycaemic – Unilateral large lesion – Organ failure with transtentorial – Electrolyte disturbance herniation – Toxic – Infratentorial 
  14. 14. Metabolic encephalopathy • Confusional state -> coma • No focal neurological sign • No neck stiffness • Normal brainstem reflexes • Coarse tremor 8-10hz • Multifocal myoclonus • Asterixis • Generalized/periodic myoclonus 
  15. 15. Supratentorial Lesions • Epidural or Subdural Hematoma • Large Ischemic Infarction • Tumour • Intraparenchymal haemorrhage • Trauma • Abscess 
  16. 16. Infratentorial Lesions• Basilar artery thrombosis• Pontine or Cerebellar Hematoma• Ischemic Cerebellar Infarction• Tumour• Abscess 
  17. 17. History• Circumstances and temporal profile• Of the onset of coma• Details of preceding neurological• Symptoms headache, weakness seizure• Any fall• Use of drug and alcohol• Previous medical illness liver,kidney• Previous psychiatric illness 
  18. 18. Other symptoms of coma• Yawning • Vomiting – Lateral reticular formation of – Poor localizing value the medulla – Posterior fossa expanding – Projectile ( usually nausea) lesion – Medulloblastoma ependymoma – Medial temporal, third – Raised icp -> compression of ventricular medulla – Basal meningitis• Hiccup – Ivh -> irritating fourth – Medullary lesion in the region ventricle of Third ventricle – Lateral medullary infarct (vestibular 
  19. 19. Examination• General physical examination• Evidence of external injury• Colour of skin and mucosa• Odour of breath• Evidence of systemic illness• Heart lung 
  20. 20. Neurological examination• Funduscopy• Pupil size and response to light• Ocular movements• Posture and limb movement• Reflexes 
  21. 21. Circulation Kocher-Cushing response – rise in BP- >bradycardia due to rise in ICP -> compression of floor of the iv ventricle fall in BP and tachycardia usually terminal event due to medullary failure 
  22. 22. Breathing• Forebrain – Post hyperventilation apnea – Cheyne stoke respiration• Hypothalamus midbrain – Central neurogenic hyperventilation• Basis pontis – Pseudobulbar paralysis of voluntary center 
  23. 23. Breathing in coma• Lower pontine tegmentum – Apneustic breathing – Cluster breathing – Short cycle periodic breathing – Ataxic breathing• Medulla – Ataxic breathing – Slow regular respiration – Gasping 
  24. 24. Pupil• Diencephalic (metabolic) Small reactive• Midbrain tectal Midsize,fixed• Midbrain nuclear Irregular pear shaped• 3rd nerve Fixed widely dilated• Pontine Pinpoint reactive• Opiate Pinpoint• Organophosphorus Small• Atropine Wide dilated 
  25. 25. Eye movement• Metabolic – Roving eye movement, – Oculocephalic, – Vestibuloocular• Supratentorial – Contralateral conjugate palsy• Thalamus – Upper turn down 
  26. 26. Eye movements in Coma• Midbrain – Ipsilateral 3rd• Pontine – Ipsilateral 6th – Ipsilateral gaze palsy – One and half syndrome – Bilateral gaze palsy – Ocular bobbing – Mlf syndrome 
  27. 27. Posture• Cerebral hemisphere • Upper brain stem – Decorticate posture – Decerebrate posture• Diencephalon • Pontine supratentorial – Abnormal ext arm – Diagonal posture – Weak flexion leg • Medullary – Flaccidity 
  28. 28. ECG changes in coma(SAH, ICH, INFARCT) – Tall T, prolonged QT – Q wave with st depression – SVT, AF, AFL – Sinus bradycardia,arrest, nodal rhythm – A-V block or dissociation – PVcs, VFL, VF 
  29. 29. Further investigation• CSF examination: neck stiffness without localizing sign• CT scan/ MRI: Focal neurological sign or before LP• X-ray chest: Aspiration, chest infection, heart size• Ultrasound abdomen: Liver, kideny, bladder 
  30. 30. Agitated1. Reassurance2. Narcotics – Small doses administered – Intravenously3. Sedation • Should follow analgesia • Sedation in presence of pain causes agitation, • Titrate intravenously so that agitation is blunted, • Do not induce excessive drowsiness 
  31. 31. Agitated patient5. General management • Face a window for day/night orientation • Clock, calendar • Have friend or family member stay with patient • Light the room if illusions, paranoia occur at night • Provide eyeglasses, hearing aids • Have staff identify themselves to patient • Explain all procedures • Provide radio, reading, TV 
  32. 32. Coma Subsequent management • Eye, mouth, skin • Fluid electrolyte, feeding • Respiration, circulation • Urine, bowel • Stimulation • Infection

The management of coma and confusional states are well known in medicine and have been around since at least 1998. BUT, in the case of the mentally ill, this approach is simply not performed by emergency health personnel . This is the true stigma of mental illness. The mentally ill do not even merit measurement of the basic circulatory and metabolic vital signs [respiratory rate and depth, blood pressure, heart rate and body temperature] or of pH or PCO2, a common cause of metabolic derangement affecting the brain, mood or an assessment of global mental state. This is the result of psychiatric mumbo jumbo interfering with a real medical assessment. The psychiatric mumbo jumbo is part of the stigma that the mentally ill deal with.

The stigma of psychiatric illness is the refusal of basic medical [not psychiatric] emergency assessment and care given to patients with different presentation of “alterations in global mental state”. The reason for this error in patient care is the outdated existence of the concept of psychiatric assessment rather than emergency medical and neurologic ongoing assessment.

For major depression and bipolar illness, a new emphasis of possible respiratory pump failure and hypercapnia needs to be developed. Arterial blood gases need to be ordered if respiratory rate is chronically too slow or too fast at rest, as this suggests that metabolic mechanisms are facing and medical supportive care needs to be given.

The solution to assessing and treating severe mental disorders already exists; it is found in the management of coma and confusional states.

We simply have to train psychiatrists in critical care neurology and in internal medicine in order to have them really help and possibly cure these severely ill patients.

That is the answer. It is in front of us. We need only to look. We need only to measure the 4 vital signs for a start; respiratory rate, blood pressure, heart rate and body temperature and then, if one has the correct medical and metabolic knowledge, the answer will be clear.

And then , we will be able to study the best treatments for the metabolic derangements afflicting these poor lost patients. Then and only then.


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