Management of the comatose patient

Abstract

Management of coma demands immediate action. The recognition of a probable cause, triage, and treatment of coma represent medical or surgical emergencies that do not allow any delays in diagnosis or treatment implementation. This chapter summarizes the main priorities in the treatment of patients with coma. The chapter reviews concepts on supportive care that must be provided on arrival to the emergency department and subsequently in the intensive care unit. The chapter describes the aspects of management according to the underlying cause of coma, with specific emphasis on those diagnoses that are encountered by practicing clinicians. When the brain is acutely injured, any additional insult directly worsens outcome and reduces the potential for functional recovery. Avoiding secondary neurological insults from hypoxia or ischemia must be a priority from the time of initial evaluation in the field. Upon arrival in the emergency department, the patient must be reassessed to ensure that vital signs are stable, and a more detailed systemic and neurological examination must be performed to decide if emergency neurosurgery is indicated. Recognizing the type of coma on the basis of categories―such as (1) supratentorial mass lesion with brain herniation, (2) diffuse cortical damage, (3) bilateral diencephalic damage, (4) infratentorial mass lesion with brainstem compression, (5) brainstem structural lesion, and (6) diffuse cerebral dysfunction―narrows the differential diagnosis and has a direct impact on treatment and prognosis. Neurological examination has to be supplemented with neuroimaging and specific laboratory tests to find the explanation for coma. Treatable causes may only be compatible with good recovery if diagnosed promptly. Some patients awaken rapidly but others require prolonged periods of support and assistance. Supportive measures include prevention or treatment of airway tract or pulmonary infections, prevention of decubitus ulcers, eye and mouth care, and physical therapy to minimize the risk of contractures.