Surgical management is the primary treatment for the structural coma, while the metabolic coma requires predominantly medical treatment. The list of metabolic causes of coma is quite long, with hyponatremia, hypoglycemia, uremia, and acute hepatic failure being the most typical. A procedure or medications to relieve pressure on the brain . The diagnosis of alcoholic coma is made only when there is a high blood alcohol level and signs of bilateral cortical dysfunction, without focal neurologic signs, and when all other metabolic and structural causes of coma have been ruled out. structural causes of coma - intracranial mass lesions that cause coma may be located in supratentorial compartment or infratentorial compartment - coma is caused by compression of the RAS and disruption of axoplasmic flow - The rate of evolution of a mass dictates whether the anatomical distortion precedes The key is the history - structural causes of coma present rapidly, and are far more likely to have a focal exam (that is, one area of the body is different than the other) than metabolic causes, which have a more gradual onset and are nonfocal in general. Chapter 7 Approach to Management of the Unconscious Patient. encephalitis or abscess). Structural cause of coma. Metabolic or infectious etiologies may diffusely affect the brain and lead to a coma. Assuming the visual pathways to the lateral geniculate body are intact, assessment of the pupillary responses is important in localising the site of coma and separating structural from toxic/metabolic causes, as pupillary responses in the latter are generally intact (fig 4). Many causes of both intracranial and systemic origin can cause coma. Structural coma can be due to cerebral infarction, intracranial hemorrhage, intracranial malignancy and central nervous system infec-tion (e.g. Structural means there is an anatomical reason for the coma, metabolic means that there is a metabolic derangement responsible for the coma. 6 Table 18-1 provides . Doctors might give breathing assistance, intravenous medications and other supportive care. Study objective: The objective was to investigate if some routinely recorded clinical features may help to distinguish between these 2 main forms of coma in the emergency department (ED). The three main mechanisms of coma are structural brain . Coma can be caused by damage to the brainstem ( Fig. Overall mortality is 25-87%. 5 Metabolic causes of coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. The first priority is to stabilise the patient by treatment of life . encephalitis or abscess). causes a decrease in overall brain size •Tension on cerebral vessels occurs •Cerebral metabolism Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. Differentiating Toxic-Metabolic Coma from Structural Coma. The Flip Side Hypercapnia •Increased ICP . Coma is a medical emergency. Thus, the highest score possible is 15. Opens eyes to voice = 3; Opens eyes to pain = 2. Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. Structural causes included intracerebral haem- It then describes the emergency treatment, both medical and surgical, of patients with specific disorders of consciousness and their prognosis. If the oculocephalic reflex is absent, cold caloric testing can be used to provide a stronger stimulus and test this more . These structures are vulnerable to toxins, metabolic derangements, and mechanical injury. Structural causes Structural causes of coma are relatively rare. Eye Opening: P atient spontaneously opens eyes = 4. Non-structural coma in-clude coma as a result of poisoning, epilepsy, extracranial More commonly, however, patients with tumors have a slow progression of neurologic . Localized, unilateral lesions in the cerebral cortex do not usually induce altered mental status or coma, even with other cognitive functions being impaired. Multifocal structural pathology, such as venous sinus thrombosis, bilateral subdural haematomas, vasculitis or meningitis, can present with coma without focal signs or meningism and so mimic toxic or metabolic pathologies. Definition. Pupillary response. Broadly speaking, structural causes of coma can be grouped into vascular 158 Karpenko & Keegan By far the most common cause of cerebral space-occupying lesions are tumours, either primary or secondary. Treatment is guided by the underlying etiology. Chapter 3 Structural Causes of Stupor and Coma. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. In a comatose patient, alertness and awareness are completely lost. The third and fourth chapters review the pathophysiology of structural lesions causing coma, and the specific disease states that result in coma. Structural brain diseases such as subdural or epidural traumatic hematomas, spontaneous intracranial hemorrhages, venous thrombosis, tumors, acute hydrocephalus, raised intracranial pressure, anoxic brain injury, or brainstem strokes may all cause altered mental status or coma. For structural causes of coma, think of a focal area of injury that interrupts the reticular activating system and its projections in the brainstem, thalami or bilateral cerebral hemispheres. Despite stroke being the overall most common cause of non-traumatic coma, the total non-structural causes (37 to 75%) tended to slightly outnumber the structural causes (28 to 64%). 94.1 ), the cerebral cortex, or both. Intact oculocephalic reflexes argue strongly against a structural cause of coma. Box 94.2 Structural Causes of Altered Mental Status and Coma Structural and diffuse causes of coma are not isolated from one another, as one can lead to the other in some situations. Common non-structural causes of coma include anoxic-ischemic encephalopathy, seizures, metabolic alterations, endocrinopathies, systemic infections, CNS infections, overdose of medications, illicit drug and alcohol use, and exposure to toxins (Table 5).Treatment is guided by the underlying etiology. Methods: Adults admitted to an ED in Stockholm between February 2003 and May . If you find any one of these diagnosis, first, you will confirm a central structural cause of coma, second, you will arrange for confirma-tory CT brain and call neurosurgery. Metabolic causes included drug overdose, acute alcohol intoxication, hypoglycaemia, sepsis, and pneumonia. It was metabolic in 69 patients (60%) and structural in 46 patients (40%). The most severe picture in the spectrum of consciousness disorders is coma. Chapter 8 Brain Death. Metabolic Coma. Another example is brainstem intracerebral hemorrhage. Although most patients with encephalopathy will have milder disturbances of level of consciousness. Focality due to structural changes Diffuse changes due to encephalopathy/delirium Morphology, frequency, amplitude, reactivity, variability Correlate with the clinical picture and imaging . In contrast to coma, patients with PVS are in a state of partial arousal and may briefly alert to sound or visual stimuli. Coma implies dysfunction of cerebral hemispheres, medulla and brain stem structures. Coma implies dysfunction of cerebral hemispheres, medulla and brain stem structures. Two major classes of structural brain injuries cause coma (Table 3-1): (1) Compressivelesions may impair consciousness either by directly compressing the ascending arousal system or by distorting brain tissue so that it moves out of position and secondarily compresses components of the ascending arousal system or its forebrain targets (see herniation syndromes, page 95). Other causes Although the general approach is similar, the likelihood of a structural cause of coma is high in patients who have experienced trauma. Structural causes Structural causes of coma are relatively rare. The causes of coma can be divided into structural versus causes of diffuse neuronal dysfunction. Another example is if cerebral edema, a diffuse dysfunction, leads to ischemia of the . Metabolic causes included drug overdose, acute alcohol intoxication, hypoglycaemia, sepsis, and pneumonia. It may be caused by neuronal dysfunction from many causes including structural or nonstructural processes affecting the central nervous system. While the causes of unconsciousness are varied, physicians generally divide them into structural and metabolic etiologies upon the dominant approach. structural causes of coma - intracranial mass lesions that cause coma may be located in supratentorial compartment or infratentorial compartment - coma is caused by compression of the RAS and disruption of axoplasmic flow - The rate of evolution of a mass dictates whether the anatomical distortion precedes 5 Coma demands immediate attention, resulting in a high percentage of admissions to all hospital services. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical . By far the most common cause of cerebral space-occupying lesions are tumours, either primary or secondary. 18. Swift action is needed to preserve life and brain function. Coma is an acute, life-threatening condition of unresponsiveness or a prolonged loss of consciousness. Stroke and anoxic coma had the highest mortality at 60 to 95% and 54 to 89% respectively. •••. Coma represents brain failure. Prognosis of AS/Coma Recovery depends primarily on the causes Intoxication and metabolic causes carry the best prognosis Coma from traumatic head injury far better than those with coma from other structural causes Coma from global hypoxic-ischemic carries least favorable prognosis At 3rd day, no papillary light reflex or GCS < 5 is associated . Wernicke encephalopathy: eg, alcoholism and other causes of malnutrition Abnormal eye movements, ataxia Management of Alteration of consciousness Treatment. 3, 6 The depth of coma at presentation also affects prognosis; those who have a higher GCS at presentation, maintain normal brainstem . Coma caused by structural cerebral disease carries the worst prognosis with only 7% of patients achieving moderate or good recovery. Non-structural causes of coma • Acute metabolic or endocrine disorder Acute metabolic disorders cause impaired consciousness, and coma rapidly, if not recognized in time. The comatose patient is unaware of self and environment and cannot be roused to respond to vigorous stimulation. The ethanol-induced hypoglycemic coma of youth appears to … Mortality for all spindle coma causes 56/242 (23%) Etiology predicted outcome If very severe the patient can become obtunded and slip into a coma with non-structural cause. Causes of diffuse neuronal dysfunction can be further . Damage may be focal or diffuse. Abstract. Overall mortality is 25-87%. Results: Aetiology of coma was determined in 98% of the patients. Definition. The causes were sepsis (one), hepatic encephalopathy (one), and pneumonia (one). The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. New chapters describe the approach to the diagnosis of brain death and the clinical physiology of the vegetative state and . sent with coma, rather than those that are uncommon or in which coma is a late finding. • Coma due to depressant drugs carries an excellent prognosis provided that resuscitative and supportive measures are available and no anoxia has been sustained • Metabolic causes, apart from anoxia, carry a better prognosis than structural lesions and head injury Common non-structural causes of coma include anoxic-ischemic encephalopathy, seizures, metabolic alterations, endocrinopathies, systemic infections, CNS infections, overdose of medications, illicit drug and alcohol use, and exposure to toxins (Table 5). Structural Causes It is critical in patients with undifferentiated coma to exclude structural causes, because they form some of the most acute and in many cases very treatable causes of coma. Causes may be structural or nonstructural (eg, toxic or metabolic disturbances). Determination of the cause of non-traumatic coma is a challenge for the physician. If a patient goes into a comatose state slowly, has no focal findings, and has preserved pupillary functions, you would expect the cause of the coma to be. Differential diagnosis of coma. Chapter five is a comprehensive treatment of the many causes of metabolic coma. Examples are basilar artery occlusion with brainstem ischemia or infarction. Lesions above the thalamus and below the pons preserve pupillary . Other causes The simple clinical assessment of neurological function with special reference to the level of coma, focal neurological signs, and brainstem reflexes The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. Coma is a state of prolonged unconsciousness that can be caused by a variety of problems — traumatic head injury, stroke, brain tumor, drug or alcohol intoxication, or even an underlying illness, such as diabetes or an infection. For instance, coma induced by a diffuse metabolic process, such as hypoglycemia, can result in a structural coma if it is not resolved. hypoglycemia cause neuronal death if not promptly corrected, so these basic measures are critical. RESULTS: Aetiology of coma was determined in 98% of the patients. Common toxic or metabolic causes of coma include hypoglycemia, hyperglycemia . Diffuse, multifocal, or metabolic causes of coma, stupor, and delirium (click image to enlarge) Diffuse, multifocal, or metabolic causes of coma, stupor, and delirium (continued) (click image to enlarge) One year follow up was obtained in all patients. . what are structural causes of coma? . Structural and diffuse causes of coma are not isolated from one another, as one can lead to the other in some situations. For instance, coma induced by a diffuse metabolic process, such as hypoglycemia, can result in a structural coma if it is not resolved. Chapter 5 Multifocal, Diffuse, and Metabolic Brain Diseases Causing Delirium, Stupor, or Coma. Coma is a medical emergency. Talk to our Chatbot to narrow down your search. A coma is a medical emergency. causes and non-structural causes of NTC by means of a computer tomography (CT) scan [5]. Structural and diffuse causes of coma are not isolated from one another, as one can lead to the other in some situations. Which of the following assessment tools is most helpful when trying to differentiate metabolic causes from structural causes of coma? The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical . Chapter 4 Specific Causes of Structural Coma. Treatment varies, depending on the cause of the coma. Doctors will first check the affected person's airway and help maintain breathing and circulation. Intracerebral space-occupying lesions cause coma, either as a result of their mass effect on the brain, or because of the anatomical position of the lesion. Check the full list of possible causes and conditions now! Common metabolic causes of stupor and coma. The important structural and metabolic causes of coma are reviewed in detail. Conversely, any toxic/metabolic cause for coma may be associated with focal findings—for example, hypoglycaemic Stroke and anoxic coma had the highest mortality at 60 to 95% and 54 to 89% respectively. Structural causes of coma and stupor (click image to enlarge) Mechanisms of coma in compressive lesions. A comatose trauma patient is suspected to have intracranial bleeding unless it is ruled out. ONSD has a great role of diagnosis of increased ICP [16,17]. Central-nervous-system-disorder & Coma Symptom Checker: Possible causes include Postinfectious Encephalomyelitis. A normal Doll's eyes response is when the head is rapidly turned, the eyes . The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. Structural brain diseases such as subdural or epidural traumatic hematomas, spontaneous intracranial hemorrhages, venous thrombosis, tumors, acute hydrocephalus, raised intracranial pressure, anoxic brain injury, or brainstem strokes may all cause altered mental status or coma. Structural Physical damage to the brain that impairs function in the either the RAS or areas of the cerebrum . 7. Multifocal structural diseases such as vasculitis or leukoencephalopathy are an exception to this rule, as they may exhibit slow progression 3. Independent predictors for structural causes of coma; results are % (95% confidence interval) There were three patients with coma of metabolic origin who had anisocoria. The prognosis of traumatic coma is better than that of non-traumatic coma. For instance, coma induced by a diffuse metabolic process, such as hypoglycemia, can result in a structural coma if it is not resolved. Fourth step Look at the TCD signs of increased ICP, bilateral dilatation of ONSD and increased MCA PI. Chapter 6 review psychiatric causes of unresponsiveness and how to identify and treat them. Chapter 6 Psychogenic Unresponsiveness. It was metabolic in 69 patients (60%) and structural in 46 patients (40%). • Coma due to structural lesions usually progresses, whereas toxic or metabolic coma is usually stable or improves. An important first discrimination should be made between structural causes and non-structural causes of NTC by means of a computer tomography (CT) scan . Coma is an acute, life-threatening condition of unresponsiveness or a prolonged loss of consciousness. Intracerebral space-occupying lesions cause coma, either as a result of their mass effect on the brain, or because of the anatomical position of the lesion. Note, that the lowest possible score is 3 (eyes 1, verbal 1, motor 1). Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. -Coma -Death Most patients show signs of agitation. The approach to scoring the GCS is given in more detail below. Despite stroke being the overall most common cause of non-traumatic coma, the total non-structural causes (37 to 75%) tended to slightly outnumber the structural causes (28 to 64%). The mechanism for coma or impaired consciousness involves dysfunction of both cerebral hemispheres or of the reticular activating system (also known as the ascending arousal system). This article will let you know what happens when someone is in a coma and types, and causes, recovery time of coma Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. This article will let you know what happens when someone is in a coma and types, and causes, recovery time of coma encephalitis or abscess). slowly progressing deep coma (8). *Patho:-lesions destroys of compresses brainstem arousal areas; either directly or secondary to more distand expanding mass lesions *Resp:-irregular, esp cheyne-stokes or ataxic breathing-also with selectedsterotpical patterns like "apenustic" respiration or central Both are quite broad terms. What are Metabolic causes of coma? Coma is a state of prolonged unconsciousness that can be caused by a variety of problems — traumatic head injury, stroke, brain tumor, drug or alcohol intoxication, or even an underlying illness, such as diabetes or an infection. Reversible injury - sedative overdose Irreversible injury - hypoxia in cardiac arrest: However, this reflex may be muted in deep metabolic coma, so symmetric absence of eye movements doesn't necessarily prove a structural lesion. Coma-explaining pathologies were identified retrospectively and grouped into primary brain pathology with proof of acute brain damage and other causes without proof of acute structural pathology. Another example is if cerebral edema, a diffuse dysfunction, leads to ischemia of the . A score of less than 8 indicates coma. 1. Meningitis, encephalitis Nuchal rigidity, seizure, cranial nerve abnormalities (especially sixth nerve) 8. Supratentorial mass lesions Acute obstructive hydrocephalus Infratentorial mass lesions: Term. Another example is if cerebral edema, a diffuse dysfunction, leads to ischemia of the . Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. Background: Patients presenting unconscious may reasonably be categorized as suffering from a metabolic or structural condition. More options. A structural cause of coma, such as a hemorrhage, ischemic infarction, or mass lesion, is more likely in the presence of asymmetrical neurological signs. STRUCTURAL CAUSES OF COMA Tumors Tumors may cause coma by exerting pressure on either a key area (eg, the brainstem) or by causing a diffuse increase in intracranial pressure. Causes of coma are thus classed in three groups— structural brain disease, diff use neuronal dysfunction (resulting from various conditions that produce a general state of depressed neuronal function), and psychogenic unresponsiveness.4 Other than psychiatric causes, all these diagnoses aff ect the cerebral cortex, the Traumatic causes of coma include subdural or epidural hematomas, focal intracerebral hemorrhage with mass effect and midline shift, bilateral contusions, direct injury to the brain stem, and diffuse axonal injury. • In addition to basic care of a comatose patient, specific measures include drug clearance therapy, removal of the unabsorbed drug, and use of drug antagonists, which may be combined in some cases. The time course: structural lesions have a more abrupt onset, whereas metabolic or toxic causes are more slowly progressive 2. Work8up+ • Guided)by)the)physical)exam) • After)vitals,)itis)importantto)do)athorough)neurological)examination,)looking)for)clues)thatwould) suggeststructural . Coma is a state of profound unresponsiveness caused by structural, metabolic, physiologic, or psychogenic brain dysfunction. Plum and Posner's Diagnosis and Treatment of Stupor and Coma, 5th edition, is a major update of the classic work on diagnosing the cause of coma, with the addition of completely new sections on treatment of comatose patients, by Dr. Jan Claassen, the Director of the Neuro-ICU at Columbia New York Presbyterian Hospital. Assessment of temperature is crucial because both hypothermia and hyperthermia can cause altered mental status from infectious, structural , environmental exposure, or toxic or metabolic causes . So there is overlap between severe encephalopathy and non-structural causes of coma. Structural or biochemical damage or disruption of this neural network may cause unconsciousness. Metabolic Coma. Structural causes of coma include ischemic stroke, intracerebral hemorrhage (ICH), trauma, and brain tumors. It is important to discriminate between structural causes and non-structural causes. Swift action is needed to preserve life and brain function. Structural coma can be due to cerebral infarction, intracranial hemorrhage, intracranial malignancy and central nervous system infection (e.g. Coma — Definition and Types See online here Coma is a life-threatening process that often requires immediate recognition, appropriate diagnosis of the cause, and proper initial management. Structural coma can be due to cerebral infarction, intracranial hemorrhage, intracranial malignancy and central nervous system infection (e.g.

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