COMA
1.Description
Coma is a state of deep, unarousable unconsciousness with total loss of awareness of self and environment.
It results from alteration of consciousness due to disease, poisoning, or trauma.
2. Causes and Presentation
| Coma with Fever | Coma without Fever |
|---|---|
| Meningitis/sepsis | Metabolic disorder |
| Cerebral malaria | Hypertensive encephalopathy |
| Viral meningo-encephalitis | Post-ictal state |
| Non-convulsive status epilepticus | |
| Stroke | |
| Poisoning/intoxications | |
| Mass brain lesions with raised ICP |
3. Investigations
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Blood glucose
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Malaria parasite slide or rapid diagnostic test (RDT)
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FBC, renal function tests, electrolytes (including calcium, phosphate, and magnesium), and blood culture
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Liver function tests (LFTs)
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Blood and urine toxicology
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Cerebrospinal fluid (CSF) studies — only if not contraindicated
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EEG (Electroencephalogram)
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X-rays to localize infection
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Neuroimaging (CT or MRI) based on clinical findings and judgement
4. Treatment
General Principle
Treat any established cause based on history and physical examination.
Primary Assessment / Resuscitation
| Step | Key Points |
|---|---|
| A – Airway | Ensure airway patency, perform airway manoeuvres as needed. |
| B – Breathing | Assess effort (recessions, RR, grunting, nasal flaring, accessory muscle use); assess effect (HR, skin colour, mental state, cyanosis); note breathing pattern (Cheyne–Stokes). |
| C – Circulation | Check pulse volume and rate, capillary refill time, and blood pressure. |
| D – Disability | Assess consciousness level using AVPU (Alert, Verbal, Pain, Unresponsive); note posture (decorticate, decerebrate, hemiparesis), pupils, and seizure activity. |
| E – Exposure | Check temperature, look for rash, and assess for evidence of poisoning. |
5. Degree of Coma
Measured using the Glasgow Coma Scale (GCS).
| Response | >1 Year | <1 Year | Score |
|---|---|---|---|
| Eye Opening | Spontaneously | Spontaneously | 4 |
| To verbal command | To shout | 3 | |
| To pain | To pain | 2 | |
| No response | No response | 1 | |
| Motor Response | Obeys | Spontaneous | 6 |
| Localises pain | Localises pain | 5 | |
| Flexion withdrawal | Flexion withdrawal | 4 | |
| Abnormal flexion (decorticate rigidity) | Abnormal flexion (decorticate rigidity) | 3 | |
| Extension (decerebrate rigidity) | Extension (decerebrate rigidity) | 2 | |
| No response | No response | 1 | |
| Verbal Response | Oriented | Appropriate words/phrases | 5 |
| Disoriented/confused | Inappropriate words | 4 | |
| Inappropriate words | Persistent cries/screams | 3 | |
| Incomprehensible sounds | Grunts/agitated/restless | 2 | |
| No response | No response | 1 |
Total GCS range: 3 – 15
6. Monitoring and Follow-up
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Continuous monitoring of airway, breathing, circulation, and neurological status.
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Regular assessment of GCS and vital signs.
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Manage according to identified cause (infection, metabolic, trauma, or poisoning).
7. Summary Table
| Parameter | Key Points |
|---|---|
| Definition | Deep unarousable unconsciousness with total loss of awareness of self and environment. |
| Major Causes | CNS infections, metabolic disorders, trauma, toxins, vascular events. |
| Key Investigations | Blood glucose, malaria test, renal/electrolyte profile, CSF (if safe), imaging. |
| Emergency Priorities | ABCDE assessment, identify and treat cause, prevent secondary injury. |
| Scoring Tool | Glasgow Coma Scale (3–15). |
8. Key Takeaways
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Coma is a medical emergency requiring immediate ABCDE assessment.
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Infectious and metabolic causes are common in Zambian settings.
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GCS is vital for assessing depth and monitoring progress.
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Management should always include treatment of the underlying cause and supportive care.