Coma and

syncope
By:
Sara Ma’rouf: Coma definition and causes.

Mays Al-shayeb: GCS, brain death and vegetative state.

Ro’a Abo Fares: Approach unconscious patient (Hx&PE).

Ali Boabbas: coma management.

Ahmad boabbas: syncope definition and causes.

Tasneem Hussein: intervention and management for

Coma
 Glasgow
coma scale
(GCS)
What is Glasgow coma scale?
It is a neurological scale used to reliably measure a person's level of
consciousness after a brain injury.
Developed by University of Glasgow in 1974.

Why is it important?
Any change in Level of consciousness (LOC) is always the first sign
that appears on your patient and GCS can detect that.
3 brain levels that are assessed by GCS:
1. Cortex: where many of the higher-level functions take
place (e.g. decision-making and language).

1. Subcortical: where we process more primitive functions.

1. Brain stem: where basic (almost reflex like) responses in

our body.

** if the damage reached the brain stem and altered its

function severe brain damage.
Glasgow coma scale assessment:
Based on the persons ability to perform eye movements,
speak, move their body.

The highest score one

can get on GCS is 15
which means that
there is no brain
damage.
The lowest score one
can get is 3.
4 steps when assessing the patient…
1) Check:
If there is any factors that may interfere with your assessment.
If there is any hearing impairment that will cause difficulty in communication.
2) Observe:
any spontaneous movements.
3) Stimulate:
sites of physical stimulation are fingertip pressure (peripheral), trapezius pinch
and supraorbital notch (central).
4) Rate:
15 fully conscious.
13-15 Mild brain damage.
9-12 Moderate damage.
3-8 Severe damage. (High chance of being in a coma)
 The first criteria is eye opening:
Highest score is 4 lowest is 1
This starts as soon as you enter the room if the patient open their eyes
spontaneously then it is a 4.
If they didn’t try calling their name, quietly first then raise your voice. If
they open them then it’s a 3.
If not yet try pressuring their nail bed for 10 seconds or pinch the
trapezius, if they open their eyes then it is a 2.
If they didn’t open them at all even after all of this, then it is a 1.
If the patient cannot open their eyes for some
reason (e.g: Edema, trauma, dressings) you should
document that the test is non testable “NT”.
 (4) Points spontaneous eye opening.
(3) Points eye opening to sound.
(2) Points eye opening to pressure.
(1) Points no eye opening.
(NT) if there is a local factor that prevent eye opening.
 Verbal response:
Higher score is 5
Ask the patient about their name and where are they? What month or
year is it? If they answered these tree questions correctly then it is a (5).

If they looked confused and starting talking and gave you full
meaningful sentences but they are not related to your questions, then
it is a (4).
If they gave you meaningless words that does not make any sense it is
a (3) then.
If they started making sounds without words, then it is a (2).
IfIf nopatient
the verbal response
can't (1)mute, intubated) then you write on the test (NT).
talk (deaf and
 (5) Points oriented to person, place and time.
(4) Points confused –proper sentences but not related to
the subject-
(3) Points words
(2) Points sounds
(1) Points no verbal response
(NT) if there is a local factor that affect the test.
Motor response:
Highest score is 6
Ask the patient to do a 2 steps action (like open their mouth and stick out their
tongue or grasp and release your fingers with their hand) If they obey your orders
then it is a (6).
If they didn’t obey then central pain stimuli is needed (trapezius pinch,
supraorbital notch) for 10 seconds.
If the patient moved their arm to the place of stimulation and moved your arm
away, then it is a (5).
If they withdrew (moved their body away from the pain) then it is a (4).
If they moved their arms to their chest (decorticate posture) then it is a (3).
If they extended their elbow other than flexing it (Decerebrate posture), you give
it (2).
If you didn’t see any movement then it is a (1).
If the patient is paralyzed and cant move you
must note that, and it becomes (NT).
(6) Point obey commands.
(5) Points Localizing (move their arms to the site and move
your arm).
(4) Points Withdraw to pain.
(3) Points Abnormal flexion (decorticate posture)
(2) Points extension (decerebrate posture)

(1) Points no motor response.

(NT) patient is paralyzed.
E.g: your patient opened their eyes to verbal stimulation,
responded with incomprehensible sounds and withdraw to the
pain you stimulated.
E:3, V:2, M:4 = 10
 GCS problems:
1. It wont give you the complete picture about the patient's case, you should
run farther more specific complex neurological testing to know the causes.
But it is important to see LOC giving that it’s the first thing changing in
case of damage.
2. Single score doesn’t give you the complete picture, assess the patient more
than one time.
3. If you're dealing with a patient that is intubated the highest score they are
going to get is 11 because they can't, give any verbal response (V1).
4. If your patient is sedated, they will score very low even if there is no brain
damage.
Brain death
 • It is a complete loss of brain function (including involuntary activity necessary to sustain life).
• Irreversible brain damage may have occurred with permanent destruction of brainstem
function (total lack of vital signs “heartbeat and respiration”).
• No response to pain and no cranial nerve reflex including papillary response (fixed pupils),
oculocephalic reflex (doll head eye), corneal reflex, no response to the caloric reflex test, and
no spontaneous respiration.
• Patients classified as brain-dead can have their organs surgically removed for organ
donation.
Diagnosis:
1. A person must be unconscious and fail to respond to outside stimulation.
2. A person heartbeat and breathing can only be maintained using a ventilator.
3. There must be clear evidence that serious brain damage has occurred, and it can’t be cured.

Ruling out any other conditions:

1. Overdose of illegal drugs, poisons or other chemical agents.
2. An abnormally low body temperature (<32).
3. Severe hypothyroidism.
Test:
1. Torch is shone into both eyes to see of they react to light (pupillary response).
2. Stroke the eye with a tissue and see the reaction (corneal reflex), if absent brain
death.
3. Insert something into the throat and look for pharyngeal contraction (gag reflex).
4. Ice-cold water is inserted into each ear, which would usually cause eyes to move to
the same side (caloric reflex), absent in brain death.

1. Disconnect the person from the ventilator for a short period of time and see if they
make any attempt to breath on their own.

Brain death is diagnosed if a person fails to respond to all these tests.

Vegetative
state
 • A wakeful unconscious state (individual is unaware of self and environment), yet able
to breath spontaneously (preserved brainstem function), with a stable circulation and
cycles of eye closure and opening resembling sleep and waking.
• Also called unresponsiveness wakefulness syndrome it is not coma.
• This state may be permanent (after 4 weeks) the patient then is classified as in a
persistent vegetative state.
• Someone in a vegetative state still has a functioning brain stem which means:
- some form of consciousness may exist.
- breathing unaided is usually possible.
- there is slim chance of recovery because the brain stem cores function may be
unaffected.
Causes:
1. Disruption of blood flow to brain.
2. Severe head injury.
3. Drug overdose.
4. Stroke.
 Diagnosis:
• No evidence of awareness of self or environment.
• no purposeful and sustained response to stimuli.
• Presence of sleep-awake cycles.
• Presence of brain stem function and some reflexes.
• General incontinence.

If a person in a vegetative state for a long time, it might be considered as:

1. A continuing (persistent) vegetative state: when its been for more than 4 weeks.
Persistent vegetative state: it is a disorder of consciousness in which patients
with severe brain damage are in a state of partial arousal rather than true
awareness.
2. A permanent vegetative state: when its been for more than 6 months if caused
by a non-traumatic brain injury, or more than 12 months of caused by a traumatic
brain injury.
If a person is diagnosed with it, recovery is extremely unlikely but not
impossible.
Locked in
syndrome
 • Also known as pseudo-coma.
• Damage of the pons loss of all motor actions and most sensations of the body.
• Patient cant live without ventilator for breathing and any artificial feeding
process.
• Where the function of the reticular activation system is preserved despite
extensive brainstem damage. The patient is alert but paralyzed able to
communicate with eye movements.
• Unlike the persistence vegetation state, in which the upper portion of the brain
is damaged, and the lower portions are spared. Locked-in syndrome is caused
by damage to specific portion of the lower brain and brainstem, with no damage
to the upper brain.

Causes:
1. Heroin abuse.
2. Abscesses or tumors in the pons.
3. Toxins.
Diagnosis:
It is very difficult as most patient be in a coma prior to the locked in syndrome.
• Patient looks in a coma but with eye movement that is usually noticed by loved ones while
talking to the patient.
• MRI and EEG are the definitive diagnostic tests.
MRI will show the damaged areas of the pons and brain while the EEG shows normal brain
activity.
APPROACH TO UNCONSCIOUS
PATIENT
History is taken whenever possible from
relatives, friends , reliable attenders.
You have to make sure to ask about :
1) Patient profile : (Name , Age , job)
2) Onset: (Abrupt , gradual)
* Clarify the meaning of the terms used by the patients to
describe their Sx.

* Determine which parts of the body are affected by Pain,

weakness or sensory loss

* Be aware of terms :
- Blackouts
- Vertigo
- numbness
RECENT COMPLAINTS :

• Headache
• Weight gain / loss
• Fever
• Depression (suicidal ideas )
• Focal weakness
• Trauma
PAST MEDICAL HISTORY
• DM
• Hypertension
• Chronic lung disease
• Renal failure
• Thyroid disease
• Heart disease
** Note for any prev. neurological events
DRUG HISTORY

• Prescription drugs
• Over the counter drugs
• Complementary drugs
• Recreational drugs is a loose term that refers to legal and illegal
drugs that are used without medical supervision. There are four categories of
recreational drugs: analgesics, depressants, stimulants, and hallucinogens
•
FAMILY HISTORY
* Ask for genetic Dx affect the nervous
system :
- Neuropathies
- Ataxias
- Huntington’s Dx
- Epilepsy
- M.S
- Vascular diseases
- HTN
SOCIAL HISTORY

- Ask for occupational factors relevant to

neurological Dz.
* Exposure to toxins >> peripheral neuropathies
- Entrapment neuropathies
- Stress-related Sx & syndrome

^ Ask for marital status / any domestic violence?

- Smoking ?
- Alcohol and drug abuse
- Sexual history ? ( for syphilis & HIV)
GENERAL EXAMINATION

1) Temperature:
Hypertherima : causes of febrile coma
Hypoththerima
Hypopituitarisim
Hypothyroidism
Barbiturate
alcohol
2) Pulse
- Bradycardia: brain tumors, opiates,
myxedema.
- Tachycardia: uremia
3) Blood Pressure
- High: hypertensive encephalopathy
- Low: Addisonian crisis, alcohol
4.Respiration
- Slow : in morphine and barbiturate poisoning .
- Rapid,deep(kussmaul) respiration: in diabetic or uremic
acidosis .
- Hyperpnoea regular alternating with apnea: lesion affecting
both cerebral hemispheres.
-Central neurogenic hyperventilation: similar to kussmul’s
respiration but lesion at the junction between midbrain and
pons.
- Apneustic breathing: prolonged pause at full inspiration due
to damage to the pons or upper medulla
- Ataxic breathing: phases of deep and shallow breathing
alternate irregular : due to medullary lesion
5. Odour of breath
- Acetone: DKA

- Fetor Hepaticus: in hepatic coma

- Urineferous odour: in uremic coma

- Alcohol odour: in alcohol intoxication

6. Skin
- Injuries: traumatic causes
- Dry Skin: DKA, Atropine poisoning
- Moist skin: Hypoglycaemic coma
- Cherry-red: CO poisoning
- Needle marks: drug addiction
- Rashes: meningitis, endocarditis
Neurological examination:

■ The goal of a neurological examination in a

comatose patient is to determine if the coma is
induced by a structural lesion or from a
metabolic derangement, or possibly from both.
■ Two findings on exam strongly point to a structural lesion:
1. consistent asymmetry between right and left sided
responses.
2. abnormal reflexes that point to specific areas within the
brain stem.
Neurological examination:

■ Mental status is evaluated by observing the patient's

response to visual, auditory and noxious (i.e., painful)
stimuli.
The three main maneuvers to produce a noxious stimulus in a
comatose
patient are:
1. press very hard with your thumb under the bony
superior roof of the o orbital cavity
2. squeeze the patient's nipple very hard
3. press a pen hard on one of the patient's fingernails.
Neurological examination:
* Decorticate posturing consists of adduction of the upper

arms, flexion of the lower arms, wrists and fingers.

- The lower extremities extend in decorticate posturing.

* Decerebrate posturing consists of adduction of the upper

arms, extension and pronation of the lower arms, along with

extension of the lower extremities.

** These postures are response typically to

Neurological examination:

❑ Pupillary signs :
▪ Dilated , unreactive to light :
- Unilateral: 3 nerve compression uncal herniation.
- Bilateral : e.g. Atropine poisoning
▪ Constricted :
- Horner’s syndrome however , alone ,
this syndrome does not cause coma
- Bilateral reactive to light : metabolic coma
- Unreactive to light : pontine hemorrhage , morphine poisoning
(pin-point pupil)
Left afferent pupillary defect
Neurological examination:

❑ Extra ocular muscle examination :

1-The doll's eyes reflex
2- Caloric test: Is a test of the vestibule-ocular reflex that
involves irrigating cold or warm water or ear into
the external auditory canal
❖ If the water is warm …causing an increased rate of firing in
the vestibular afferent nerve. This situation mimics a head
turn to the ipsilateral side. Both eyes will turn toward the
contralateral ear, with horizontal nystagmus to
the ipsilateral ear
❖ If the water is cold … decreasing the rate of vestibular
afferent firing. This situation mimics a head turn to the
contralateral side. The eyes then turn toward
the ipsilateral ear, with horizontal nystagmus to
❖ In comatose patients with cerebral damage, the fast phase
of nystagmus will be absent as this is controlled by the
cerebrum.

❖ If both phases are absent, this suggests that the patient’s

brainstem reflexes are also damaged and this carries a very
poor prognosis
Neurological examination:

■ Cranial nerve V (Trigeminal) may be tested in the comatose

patient with the corneal reflex test.

■ Cranial nerves IX(Glossopharyngeal) and X(vagus) may be

evaluated with the gag reflex.
Gag reflex
Neurological examination:

■ The motor system is assessed by testing deep tendon

reflexes, feeling the resistance of the patient's limbs to
passive movements, and testing the strength of posturing
and local withdrawal movements.

■ The sensory system can only be evaluated by observing

the patient's response, or lack of response, to noxious
stimuli in different parts of the body.
Fundus examination:
For papilloedema in cases of ICP
Signs of meningeal irritation :
Neck stiffness, positive kernig’s sign and Brudsinski’s sign
in cases of meningitis and subarachnoid heamorrahge
Opisthotonus : is a symptom seen in some cases of
sever cerebral palsy and traumatic brain injury or as
a result of severe muscular spasm associated with
tetanus