Coma

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Coma
ICD-10	R40.2
ICD-9	780.01

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

In medicine, a coma (from the Greek Template:Polytonic koma, meaning deep sleep) is a profound state of unconsciousness. A comatose patient cannot be awakened, fails to respond normally to pain or light, does not have sleep-wake cycles, and does not take voluntary actions. Coma may result from a variety of conditions, including intoxication, metabolic abnormalities, central nervous system diseases, acute neurologic injuries such as stroke, and hypoxia. It may also be deliberately induced by pharmaceutical agents in order to preserve higher brain function following another form of brain trauma, or to save the patient from extreme pain during healing of injuries or diseases. A coma may also result from immense head trauma caused by something like a car accident or a series of very severe concussions. The underlying cause of the coma is bilateral damage to the Reticular formation of the midbrain, which is important in regulating sleep .

Differential Diagnosis of Causes of Coma

(Most common causes)

• Cerebral masses
• Encephalitis
• Endocrine encephalopathies
• Heatstroke
• Intoxication
• Psychoses
• Subarachnoid hemorrhage
• Syncopes

(By organ system)

Cardiovascular	Heart attack, Heart failure, Malignant hypertension, Shock, Ventricular fibrillation, Very low blood pressure
Chemical / poisoning	1,1-Dimethylhydrazine poisoning, 2-Methyl-4-Chlorophenoxyacetic Acid poisoning , Acetone poisoning, Acetylene poisoning , Ackee Fruit Food poisoning , Acrolein poisoning, Acute Chemical poisoning -- Varnish makers' and painters' Naptha, Acute xylene poisoning, Aftershave poisoning, Alcohol intoxication, Aldrin poisoning, Alicyclic hydrocarbons poisoning, Allethrin poisoning, Amanita polypyramis poisoning, Amidithion poisoning, Amiton poisoning, Ammonium Bifluoride, Ammonium Sulfamate poisoning, Anchovy (clupeotoxin) poisoning , Aniline poisoning, Antifreeze poisoning, Apricot seed poisoning, Azinfos-methyl poisoning, Azinphos-ethyl poisoning, Azinphosmetile poisoning, Azothoate poisoning, Benoxafos poisoning, Bentazon poisoning, Benzene toxicity, Beta ketothiolase deficiency, Bird cherry seed poisoning, Bitter almond seed poisoning, Black henbane poisoning, Black jetbead poisoning, Blue-ringed octopus poisoning, Boric Acid, Box Jellyfish poisoning, Bromide toxicity, Bromoform poisoning, Brown Recluse spider poisoning, Butyl Alcohol poisoning, Camphor, Cannabinoids, Carbamate insecticide poisoning, Carbaryl, Carbinoxamine, Carbon monoxide poisoning, Carbon Tetrachloride, Carbophenothion, Celandine poisoning, Cherry laurel seed poisoning, Cherry seed poisoning, Chlophedianol toxicity, Chloral hydrate poisoning, Chlorate salts poisoning, Chlorfenvinphos poisoning, Chloromethane poisoning, Chloropyrifos poisoning, Chlorpyrifos poisoning, Chokecherry seed poisoning, Christmas Cherry poisoning, Chromium poisoning, Clupeotoxism, Cobra poisoning, Cocaine, Common poppy poisoning, Cone shell poisoning, Copper toxicity, Coumaphos poisoning, Cresols poisoning, Cresylic acid poisoning, Cyanide poisoning, Daphne poisoning, Darvocet overdose, Death Angel poisoning, Death Camas poisoning, Demethyldiazepam toxicity, Demeton-O-methyl poisoning, Demeton-S-methyl poisoning, Demeton-S-methylsulphon poisoning, Devil's trumpet poisoning, Dialifos poisoning, Diazinon poisoning, Dichloralphenazone poisoning, Dichloronaphthoquinone poisoning, Dichlorvos poisoning, Dicrotophos poisoning, Dieldrin poisoning, Diethylene Glycol poisoning, Dilaudid overdose, Dimethoate poisoning, Dimethyl Phthalate poisoning, Dinitrocresol poisoning, Dinitrophenol poisoning, Di-n-Octyl phathalate poisoning, Dioxathion poisoning, Disulfoton poisoning, Endothion poisoning, English Ivy poisoning, English Laurel poisoning, Ethchlorvynol poisoning, Ethion poisoning, Ethoate-methyl poisoning, Ethoprophos poisoning, Ethylene Glycol poisoning, Ethyl-guthion poisoning, Etrimfos poisoning, Eucalyptus Oil poisoning, Fenchlorphos poisoning, Fenitrothion, Fensulfothion, Fentanyl toxicity, Fenthion poisoning, Fire cherry poisoning, Fonophos poisoning, Formaldehyde poisoning, Formothion poisoning, Funnel Web spider poisoning, Hair Bleach, Hair Dye, Heptenophos poisoning, Hexachlorobutadiene poisoning, Hyacinth bean poisoning, Imazapyr poisoning, Iodofenphos poisoning, Japanese pagoda tree poisoning, Jessamine poisoning, Jimsonweed poisoning, 1,2-Dichloromethane, Amyl Alcohol, Aristolochic acid, Arsenic, Cadmium, Carbon Tetrachloride, Chromium, Copper, Degreasing solvents, Dichloroacetylene, Diethylene glycol, Ethylene glycol ethers, Gasoline, Germanium, Glue solvent vapors, Heavy metals, Herbicide, Hexachloro-1,3-butadiene, Hydrocarbons, Lead, Mercury, Methanol, Methemoglobin-producing agents, Paint thinners, Paints, Paraquat ochratoxin A, Perchloroethylene, Platinum, Silicon compounds, Silver, Solvents, Styrene, Thallium, Toluene, Trichloroethane, Trichloroethylene, Uranium, Lantana poisoning, Lead poisoning, Lobelia poisoning, Loquat poisoning, Lupine poisoning, Magnesium Overdose, Mayapple poisoning, Mecarbam, Mephenoxalone, Metaldehyde, Methacrifos, Methamidophos, Methaqualone, Methidathion, Methyl Bromide, Methyprylon, Mexican tea poisoning, Nabilone, Naked brimcap poisoning, Omethoate poisoning, Organophosphate insecticide poisoning, Oxydeprofos poisoning, Oxydisulfoton poisoning, Parathion poisoning, Pentachlorophenol poisoning, Phorate poisoning, Phosalone poisoning, Phosdrin poisoning, Phosmet poisoning, Phosphamidon poisoning, Phoxim poisoning, Phthalthrin poisoning, Pirimiphos-methyl, Poison hemlock poisoning, Polyethylene Glycol -- Low Molecular Weight, Primiphos methyl, Profenofos, Propoxur, Prothidathion poisoning, Prothoate poisoning, Pyrimidifen poisoning, Pyrimitate poisoning, Quinalphos poisoning, Quintiofos poisoning, Ramelteon poisoning, Sardine poisoning (clupeotoxin), Selenious Acid, Slickhead poisoning (clupeotoxin), Sodium Monofluoroacetate, Sophamide, Sulfotep poisoning, Systemic monochloroacetate poisoning, Tapioca poisoning, Terbufos poisoning, Tetraethyl Pyrophosphate poisoning, Tetrahydrocannabinol, Tetramethrin poisoning, Tetramethylenedisulfotetramine poisoning, Thallium Sulfate, Thiometon, Thornapple poisoning, Tolclofos methyl poisoning, Toluene, Triazophos poisoning, Triazotion poisoning, Trichloroethane, Triclofos, Triethylene Glycol, Trifenfos, White snakeroot poisoning, Wild cherry seed poisoning, Wild Lima bean poisoning
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	ACTH resistance, Addison's Disease, Diabetic coma, Diabetic ketoacidosis, Functioning pancreatic endocrine tumor, Hyperosmolar non-ketotic diabetic coma, Hyperparathyroidism, Hypoglycemia, Hypothyroidism, Insulinoma, Metastatic insulinoma, Multiple endocrine neoplasia type 1, Multiple endocrine neoplasia type 2, Multiple endocrine neoplasia type 3, Thyroid gland failure, X-linked adrenoleukodystrophy -- Addison disease only, Pituitary apoplexy, Congenital Hyperinsulinism, Hyperinsulinism due to glucokinase deficiency, Hyperinsulinism due to glutamodehydrogenase deficiency
Environmental	Altitude sickness, acute, Comly syndrome, Dehydration, Heat stroke, Hyperbaric sickness, Hypothermia, Mountain sickness, Near-drowning, Suffocation, High altitude cerebral edema
Gastroenterologic	End Stage Liver Failure, Hepatic failure, Hepatitis, Progressive familial intrahepatic Cholestasis 2, progressive familial intrahepatic Cholestasis 3, Hepatic encephalopathy syndrome
Genetic	2-methylbutyryl-coenzyme A dehydrogenase deficiency, 3 alpha methylcrotonyl-Coa carboxylase 1 deficiency, 3 alpha methylcrotonyl-coa carboxylase 2 deficiency, 3-methylcrotonyl-CoA carboxylase deficiency, Arginosuccinic aciduria, Carbamoyl-phosphate synthase 1 deficiency, Carnitine deficiency (systemic), Carnitine transporter deficiency, Citrullinemia I, Citrullinemia II, Congenital Hyperinsulinism, Flavoprotein deficiency, Fructose-1,6-bisphosphatase deficiency, hereditary, Fructose-1-phosphate aldolase deficiency, hereditary, Fumarase deficiency, Glycine synthase deficiency, HMG-CoA lyase deficiency, Holocarboxylase synthetase deficiency, Hyperinsulinism due to glucokinase deficiency, Hyperinsulinism due to glutamodehydrogenase deficiency, Isovaleric Acidemia, Late onset Argininosuccinase lyase deficiency, Long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency, Medium-Chain Acyl-CoA Dehydrogenase Deficiency, Neonatal Argininosuccinase lyase deficiency, Ornithine transcarbamylase (OTC) Deficiency, Fatal familial insomnia, Inborn urea cycle disorder, Methylmalonic Acidemia, Methylmalonicaciduria with homocystinuria, cobalamin F, Mitochondrial acetoacetyl-CoA thiolase deficiency, N-acetyl glutamate synthetase deficiency
Hematologic	Antiphospholipid Syndrome, Hemolytic uremic syndrome, Thrombotic thrombocytopenic purpura, Waterhouse-Friderichsen syndrome
Iatrogenic	No underlying causes
Infectious Disease	Bacterial: Ehrlichiosis, Epidemic typhus, Melioidosis, Rocky Mountain spotted fever, Septicemia, Streptococcal Group B invasive disease, Typhoid fever, Vancomycin resistant enterococcal bacteremia, Brain abscess, Cerebellar abscess, Cerebral abscess, Intracranial abscess / granuloma, Meningitis, Postoperative septicaemia Virus: Herpes simplex encephalitis, Meningitis, Arbovirosis, Hendra Virus, HIV/AIDS, Kyasanur-Forrest disease, Lyssavirus, Rabies, Rift Valley Fever, Simian B virus infection, Togaviridae disease, Viral Hemorrhagic Fevers, West nile encephalitis, Western equine encephalitis, Yellow fever, HHV-6 encephalitis, Venezuelan equine encephalitis, Western/Eastern/California encephalitis Fungus: Cryptococcal Meningitis Parasites: Chagas disease, Katayama fever, Malaria, Sleeping sickness (East African), Sleeping sickness (West African), Toxoplasmosis
Musculoskeletal / Ortho	No underlying causes
Neurologic	Acute Disseminated Encephalomyelitis, ADANE, African Sleeping sickness, Alzheimer's disease, Basedow's coma, Bing-Neel syndrome, Brain abscess, Brain cancer, Brain compression, Brain cyst, Brain death, Bristowe's syndrome, Brown-Symmers disease, Cataplexy, Cerebellar abscess, Cerebral abscess, Cerebral hemorrhage, Cerebral metastases, Concussion, Creutzfeldt-Jakob Disease, Cryptococcal Meningitis, Encephalitis, Encephalomyelitis, Epidural haemorrhage, Epilepsy, Fatal familial insomnia, Hashimoto's encephalitis, Hemiplegic migraine, familial type 1, Hemorrhagic shock and encephalopathy syndrome, Hepatic encephalopathy syndrome, HHV-6 encephalitis, High altitude cerebral edema, , Hypoxic encepahalopathy, Intracerebral hematoma, Intracranial abscess / granuloma, Jamaican vomiting sickness, Japanese encephalitis, Marchiafava-Bignami disease, Meningoencephalitis, Narcolepsy, Persistent vegetative state, Pituitary apoplexy, Raised intracranial pressure, Spinal cord injury, acute, Stroke, Subarachnoid hemorrhage, Subdural haemorrhage, Traumatic Brain Injury, Vanishing white matter leukodystrophy, Venezuelan equine encephalitis, Western/Eastern/California encephalitis, Westphal-Leyden ataxia, Chagas disease, Herpes simplex encephalitis
Nutritional / Metabolic	Biotinidase deficiency, Hyperglycerolemia-juvenile form, Hyperornithinemia-hyperammonemia-homocitrullinuria syndrome, Inborn amino acid metabolism disorder, Inborn urea cycle disorder, Leucinosis, Maple syrup urine disease, Methylmalonic Acidemia, Methylmalonicaciduria with homocystinuria, cobalamin F, Methylmalonicaciduria, vitamin B12 unresponsive, Mitochondrial acetoacetyl-CoA thiolase deficiency, Mitochondrial trifunctional protein deficiency, N-acetyl glutamate synthetase deficiency, Periodic hyperlysinemia, Porphyria, Pyruvate carboxylase deficiency, Group B, Thiamine (Vitamin B1) deficiency, Urea Cycle Disorders, Uremia, Wernicke-Korsakoff syndrome, 2-methylbutyryl-coenzyme A dehydrogenase deficiency, 3 alpha methylcrotonyl-Coa carboxylase 1 deficiency, 3 alpha methylcrotonyl-coa carboxylase 2 deficiency, 3-methylcrotonyl-CoA carboxylase deficiency, Arginosuccinic aciduria, Carbamoyl-phosphate synthase 1 deficiency, Carnitine deficiency (systemic), Carnitine transporter deficiency, Citrullinemia I, Citrullinemia II, Flavoprotein deficiency, Fructose-1,6-bisphosphatase deficiency, hereditary, Fructose-1-phosphate aldolase deficiency, hereditary, Fumarase deficiency, Glycine synthase deficiency, HMG-CoA lyase deficiency, Holocarboxylase synthetase deficiency, Isovaleric Acidemia, Late onset Argininosuccinase lyase deficiency, Long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency, Medium-Chain Acyl-CoA Dehydrogenase Deficiency, Neonatal Argininosuccinase lyase deficiency, Ornithine transcarbamylase (OTC) Deficiency
Obstetric/Gynecologic	Eclampsia, Pregnancy toxemia
Oncologic	No underlying causes
Opthalmologic	No underlying causes
Overdose / Toxicity	Acetylsalicylic Acid, Amitriptyline, Amlodipine, Antipsychotic drugs, Lorazepam overdose, Atropine, Baclofen, Barbiturates, Benzodiazepine, Bromazepam, Bupivacaine, Buprenorphine, Buspirone, Chlorpheniramine, Chlorpromazine, Cinnarizine, Clonazepam, Clonidine, Clotiapine, Codeine, Colchicine, Tricyclic antidepressant, Cyclobenzaprine, Cycloserine, Dantrolene, Mepiridine, Deserpidine, Desipramine, Diamorphine, Diazepam, Diphenhydramine, Diphenidol, Disulfiram, Dothiepin, Efavirenz, Eszopiclone, Ether, Ethinamate, Felodipine, Flurazepam, Fluridrazepam, Gabapentin, Ganaxolone, General anaesthesia, Glutethimide, Haloperidol, Heroin, Hydroxyzine, Inhalational anaesthetics, Isoniazid, Isradipine, Acetaminophen, Aminoglycosides, Aminosalicylic Acid, Amphotericin B, Aspirin, Bacitracin, Bismuth, Cephaloridine, Chloroform, Chlortetracycline, Cisplatin, Contrast agents, Cyclophosphamide, Cyclosporin, Ibuprofen, Lithium, Methicillin, Neomycin, Nonsteroidal anti-inflammatory drugs, Oxytetracycline, Polymyxin, Prostaglandin synthetase inhibitors, Rifampin, Sulphonamides, Trimethropin, Levetiracetam, Levomepromazine, Lidocaine, Lofexidine, Lorazepam, Malathion, Medazepam, Meprobamate, Methadone, Methamphetamine, Methiocarb, Methyldopa, Metoclopramide, Mianserin, Midazolam, Mirtazapine, Morphine, Nimodipine, Nitrates, Nitrazepam, Nitroglycerin, Nitrous oxide, Nortriptyline, Olanzapine, Opioid, Oxazepam, Oxycontin, Perazine, Percocet, Phencyclidine, Phenelzine, Phenobarbital, Phenothiazine, Pipothiazine, Pizotifen, Pramipexole, Prazepam, Pregabalin, Primidone, Prochlorperazine, Propanol, Propiomazine, Propofol, Quetiapine, Quinidine, Reserpine, Temazepam, Thiopentone, Tizanidine, Tolterodine, Topiramate, Tramadol, Triazolam, Trifluperidol, Vicodin, Vigabatrin, Xanax
Psychiatric	Hysteria
Pulmonary	Anoxemia, Asphyxia, Lung disease, Pulmonary embolism, Respiratory acidosis, Respiratory failure
Renal / Electrolyte	Acid-Base Imbalance, Chronic Kidney Disease, End-stage renal disease, Hypermagnesaemia, Hypernatremia, Hyponatremia, Hypophosphatemia, Renal failure
Rheum / Immune / Allergy	Anaphylaxis
Sexual	No underlying causes
Trauma	Head trauma, Skull fracture
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Alcohol withdrawal syndrome, Amyloidosis, Anticholinergic syndrome, Electrocution, Fat embolism, Graft-versus-host disease, Malignant Buotonneuse fever, Neuroleptic Malignant Syndrome, Oculoleptomeningeal Amyloidosis, Postoperative haemorrhage, Postoperative septicaemia, Reye's syndrome, Self-induced water intoxication and schizophrenic disorders syndrome, Serotoninergic syndrome, Shaken Baby Syndrome, Streptococcal Toxic Shock Syndrome, Ureterosigmoidostomy, Venomous snake bites, Venomous spider bites

(In alphabetical order)

• Acute hemorrhagic leukoencephalitis
• Addisonian crisis
• AEIOU-TIPS

  • Alcohol
  • Encephalitis
  • Insulin
  • Opiates
  • Uremia
  • Trauma
  • Infection
  • Psychiatric
  • Syncope

• Apallic Syndrome
• Biguanides
• Bilateral subdural hematoma
• Blood pressure disorders
• Brain abscess with edema
• Brain hemorrhage
• Brain tumor
• Carcinomatosis meningitis
• Cardiac dysrhythmias
• Catatonia
• Cerebral infarction with edema
• Cerebrovascular disease
• Concussion
• Congestive Heart Failure
• Consciousness shift
• Creutzfeldt-Jakob Disease
• Diabetes Insipidus
• Diabetic Acidosis
• Disseminated encephalomyelitis
• Drug withdrawal
• Drugs
• Eclampsia
• Endocarditis
• Epidural hematoma
• Focal seizures
• Hepatic coma
• Herpes encephalitis
• Hydrocephalus
• Hypercalcemia
• Hypercarbie
• Hyperkalemia
• Hypermagnesemia
• Hypernatremia
• Hyperosmolality
• Hyperphosphatemia
• Hypertensive encephalopathy
• Hyperthermia
• Hypocalcemia
• Hypoglycemia
• Hypokalemia
• Hypomagnesemia
• Hyponatremia
• Hypoosmolality
• Hypophosphatemia
• Hypothermia
• Hypothyroid crisis
• Hypoxia
• Hysterical coma
• Intracerebral hemorrhage
• Locked-In Syndrome
• Malaria
• Meningitis
• Migraine
• Narrowed consciousness
• Pheochromocytoma crisis
• Pituitary insufficiency
• Pneumonia
• Porphyria
• Postictal state
• Postoperative
• Postpartum
• Profound nutritional deficiency
• Progressive multifocal leukoencephalopathy
• Pulmonary causes
• Reye's Syndrome
• Rheumatic Fever
• Septicemia
• Severe drug overdose
• Subdural hematoma
• Thiamine deficiency
• Thrombotic Thrombocytopenic Purpura
• Thyrotoxic crisis
• Tumor with edema
• Typhoid Fever
• Wernicke's Encephalopathy

Severity

The severity of coma impairment is categorized into several levels. Patients may or may not progress through these levels. In the first level, the brain responsiveness lessens, normal reflexes are lost, the patient no longer responds to pain and cannot hear.

Contrary to popular belief, a patient in a coma does not always lie still and quiet. They may move, talk, and perform other functions that may sometimes appear to be conscious acts but are not.

Two scales of measurement often used in TBI diagnosis to determine the level of coma are the Glasgow Coma Scale (GCS) and the Ranchos Los Amigos Scale (RLAS). The GCS is a simple 3 to 15-point scale (3 being the worst and 15 being that of a normal person) used by medical professionals to assess severity of neurologic trauma, and establish a prognosis. The RLAS is a more complex scale that has eight separate levels, and is often used in the first few weeks or months of coma while the patient is under closer observation, and when shifts between levels are more frequent.

Outcome

Outcomes range from recovery to death. Comas generally last a few days to a few weeks. They rarely last more than 2 to 5 weeks but some have lasted as long as several years. After this time, some patients gradually come out of the coma, some progress to a vegetative state, and others die. Some patients who have entered a vegetative state go on to regain a degree of awareness. Others remain in a vegetative state for years or even decades (the longest recorded period being 37 years).

The outcome for coma and vegetative state depends on the cause, location, severity and extent of neurological damage. A deeper coma alone does not necessarily mean a slimmer chance of recovery, because some people in deep coma recover well while others in a so-called milder coma sometimes fail to improve.

People may emerge from a coma with a combination of physical, intellectual and psychological difficulties that need special attention. Recovery usually occurs gradually — patients acquire more and more ability to respond. Some patients never progress beyond very basic responses, but many recover full awareness. Regaining consciousness is not instant: in the first days, patients are only awake for a few minutes, and duration of time awake gradually increases.

Predicted chances of recovery are variable owing to different techniques used to measure the extent of neurological damage. All the predictions are based on statistical rates with some level of chance for recovery present: a person with a low chance of recovery may still awaken. Time is the best general predictor of a chance of recovery: after 4 months of coma caused by brain damage, the chance of partial recovery is less than 15%, and the chance of full recovery is very low.

The most common cause of death for a person in a vegetative state is secondary infection such as pneumonia which can occur in patients who lie still for extended periods.

Occasionally people come out of coma after long periods of time. After 19 years in a minimally conscious state, Terry Wallis spontaneously began speaking and regained awareness of his surroundings.

A brain-damaged man, trapped in a coma-like state for six years, was brought back to consciousness in 2003 by doctors who planted electrodes deep inside his brain. The method, called deep-brain electrical stimulation (DBS) successfully roused communication, complex movement and eating ability in the 38-year-old American man who suffered a traumatic brain injury. His injuries left him in a minimally conscious state (MCS), a condition akin to a coma but characterized by occasional, but brief, evidence of environmental and self-awareness that coma patients lack.

See also

• Persistent vegetative state (vegetative coma), deep coma without detectable awareness
• Brain death (irreversible coma), irreversible end of all brain activity
• Process Oriented Coma Work, for an approach to working with residual consciousness in comatose patients

Additional Resources

• BIAUSA (Brain Injury Association of America), Types of Brain Injury.
• NINDS (National Institute of Neurological Diseases and Stroke), public domain information on TBI
• NINDS (National Institute of Neurological Diseases and Stroke), public domain information on coma