Author:

Gregory D.Jay

Signs and Symptoms

Essential Workup

• Detect and treat reversible causes
• Immediate exclusion of comalike states:
  • Noting resistance to passive opening of eyelids, fluttering of eyelids when stroked, abrupt eyelid closure, eye movements by saccadic jerks (rather than roving), or finding the eyes rolled back
  • Provocation of nystagmus with ice-water caloric testing
  • Before paralyzing a patient for intubation, an attempt should be made to detect a locked-in syndrome
  • Demonstrating that the patient is able to blink on verbal command will establish locked-in syndrome
  • Intubation is still indicated to prevent aspiration

Diagnostic Tests & Interpretation

Differential Diagnosis

• Locked-in syndrome
• Psychogenic unresponsiveness
• Stupor
• Catatonia
• Akinetic mutism

Prehospital

• Airway management if loss of airway patency
• Endotracheal intubation if no response to coma cocktail
• IV access
• Dextrose or Dextrostix
• Narcan
• Monitor
• Look for signs of an underlying cause:
  • Medical alert bracelets
  • GCS
  • Pupils
  • Extremity movements

Initial Stabilization/Therapy

• Airway management
• Empiric use of naloxone
• Empiric dextrose:
  • Administer if serum glucose cannot be measured at the bedside
  • Can safely be administered before thiamine
  • Does not worsen outcome in patients with stroke

ED Treatment/Procedures

• Specific therapy directed at underlying cause once identified
• Consider empiric use of antibiotics for coma of undetermined etiology:
  • Broad-spectrum with good cerebrospinal fluid penetration such as ceftriaxone
• Stop seizure activity with benzodiazepines, phenytoin, and phenobarbital
• Empiric treatment for a toxic ingestion:
  • Activated charcoal
• Correct body temperature:
  • Aggressive rewarming for patients with core temperature between 32°-35°C and invasive rewarming for <32°C
  • Ice packs and forced air movement over exposed wetted skin if severe hyperthermia

Medication

• Ceftriaxone: 100 mg/kg IV
• Dextrose: 1-2 mL/kg of D₅₀W IV; neonate 10 mL/kg D₁₀W IV; peds 4 mL/kg D₂₅W IV
• Diazepam: 0.1-0.3 mg/kg slow IV (max 10 mg/dose) q10-15min × 3 doses
• Flumazenil: 0.20 mg IV qmin × 1-5 doses
• Fomepizole: 15 mg/kg IV
• Lorazepam: 0.05-0.1 mg/kg IV (max 4 mg/dose q10-15min)
• Mannitol: 0.25-1 g/kg IV over 20 min
• Naloxone: 0.01-0.1 mg/kg
• Phenobarbital: 10-20 mg/kg IV, monitor for respiratory depression
• Phenytoin: Infuse at <50 mg/min; 18-20 mg/kg IV/IO or fosphenytoin 15-20 mg/kg IV/IO
• Physostigmine: 0.5-2 mg IV
• Thiamine: 100 mg IM or 100 mg thiamine in 1,000 mL of IV fluid wide open
• Pyridoxine: 70 mg/kg IV (max 5 g on a 1:1 basis with INH overdose)

Disposition

Follow-up Recommendations

• If discharged, urgent PCP F/U is needed
• Consideration of adverse medication reaction
• Supervision for 24 hr postdischarge
• In case of opiate poisoning, discuss options for medication-assisted treatment and use of Naloxone issued to family members

• EdlowJA, RabinsteinA, TraubSJ, et al. Diagnosis of reversible causes of coma . Lancet. 2014;384:2064-2076.
• OdiariEA, SekhonN, HanJY, et al. Stabilizing and managing patients with altered mental status and delirium . Emerg Med Clin N Am. 2015;33:753-764.
• PlumF, PosnerJ. The Diagnosis of Stupor and Coma. 4th ed.Philadelphia, PA: FA Davis; 2007.
• TraubSJ, WijdicksEF. Initial diagnosis and management of coma . Emerg Med Clin N Am. 2016;34:777-793.
• WeinerW, ShulmanL. Emergent and Urgent Neurology. 2nd ed.Philadelphia, PA: Lippincott Williams & Williams; 1999.

ICD9

780.01 Coma

ICD10

• R40.20 Unspecified coma

• R40.244 Oth coma, w/o glasgow coma scale score, or w/part score report

• R40.2110 Coma scale, eyes open, never, unspecified time

• R40.2120 Coma scale, eyes open, to pain, unspecified time

• R40.2112 Coma scale, eyes open, never, EMR

• R40.2122 Coma scale, eyes open, to pain, EMR

• R40.2132 Coma scale, eyes open, to sound, EMR

• R40.2142 Coma scale, eyes open, spontaneous, EMR

• R40.2212 Coma scale, best verbal response, none, EMR

• R40.2222 Coma scale, best verb, incomprehensible words, EMR

• R40.2232 Coma scale, best verbal response, inappropriate words, EMR

• R40.2242 Coma scale, best verbal response, confused conversation, EMR

• R40.2252 Coma scale, best verbal response, oriented, EMR

• R40.2312 Coma scale, best motor response, none, EMR

• R40.2322 Coma scale, best motor response, extension, EMR

• R40.2332 Coma scale, best motor response, abnormal, EMR

• R40.2342 Coma scale, best motor response, flexion withdrawal, EMR

• R40.2352 Coma scale, best motor response, localizes pain, EMR

• R40.2362 Coma scale, best motor response, obeys command s, EMR

• R40.241 glasgow coma scale score 13-15

• R40.242 glasgow coma scale score 9-12

• R40.243 glasgow coma scale score 3-8

• R40.24glasgow coma scale, total score

SNOMED

• 371632003 Coma (disorder)

• 275945006 On examination - comatose (disorder)

• 274659008 Semicoma (disorder)

• 230799003 Post-traumatic coma (disorder)