Coma

 What do you think about when you hear the word coma (say: ko-muh)? Does it make you think of someone in a deep sleep, or the way you feel after eating too much Thanksgiving turkey? Does the word remind you of a TV soap opera, where it seems that at least one character is always in a coma?

A coma can be difficult to understand, especially because people sometimes jokingly use the words coma and comatose (say: ko-muh-tose, which means in a coma or coma-like state) to describe people who aren't paying attention or who are drowsy or sleeping. But a coma is a serious condition that has nothing to do with sleep.

What Happens When Someone Is in a Coma?

Someone who is in a coma is unconscious and will not respond to voices, other sounds, or any sort of activity going on nearby. The person is still alive, but the brain is functioning at its lowest stage of alertness. You can't shake and wake up someone who is in a coma like you can someone who has just fallen asleep.

What Can Cause a Coma?

Comas can be caused by different things, including:

• a severe injury to the head that hurts the brain
• seizures
• infections involving the brain
• brain damage caused by a lack of oxygen for too long
• an overdose (taking too much) of medicine or other drugs
• a stroke
• Swelling
• Poisons

When one of these things happens, it can mess up how the brain's cells work. This can hurt the parts of the brain that make someone conscious, and if those parts stop working, the person will stay unconscious.

How is coma assessed?

• When a patient presents in coma, diagnosis and treatment begin simultaneously. Initial treatment is aimed at addressing immediate life-threatening issues:

• Are the ABCs intact? Is the patient's airway open? Are they breathing? Do they have good circulation (a heart beat and blood pressure)?
• Is the patient hypoglycemic? The blood sugar is checked by a quick fingerstick bedside test and if it is low, glucose is administered.
  
• Did the patient ingest a narcotic?Naloxone (Narcan) may be given intravenously to reverse an overdose situation.

History remains the important key to the diagnosis. Since the patient cannot be the source of information, questions are asked of family, friends, bystanders, and rescue personnel. For example, a person sitting at a bar fell down, hit his head and is in coma. While it might be easy to jump to the conclusion that he was intoxicated, fell, and bled in his brain, other scenarios need to be considered. Did he have a heart attack, did he suffer a stroke, or was this a diabetic medication reaction and the blood sugar is low.

Once the patient has been stabilized with acceptable vital signs, physical examination will include a complete neurologic assessment. From head to toe, this may include examination of the eyes, pupils, face movements to assess cranial nerves including facial movement and gag reflex, extremity movement and reaction to stimulation, tendon reflexes and other testing of spinal cord function. There is special attention paid to symmetry in the neurology exam, since lack of movement or response on one side of the body may be caused by bleeding inside the skull or by stroke. General examination surveys the skin for cuts, scrapes, wounds, etc.

The GCS score will be documented; the deeper the coma, the lower the score. Please appreciate that a person with a "normal" GCS of 15 still can be in coma. Once the initial screening physical examination complete, a more detailed exam will likely occur to include the lungs, the heart, and the abdomen. Repeated neurologic assessment is key to monitoring the status of the patient and decide if the coma is lightening or getting worse.

What tests are there for coma?

The strategy to decide which tests will help provide a diagnosis will depend upon the suspected cause. Many times, the cause involves many factors and the sequence of events will require serious detective work. Blood tests, electrocardiogram and CT scan of the head are most often obtained.

What is the outcome and prognosis for a patient in a coma?

Depending upon the diagnosis, the evaluation may be no more than assessing blood sugar, treating hypoglycemia, and having complete resolution of the situation. On the other hand, the cause of coma may be a catastrophic brain hemorrhage without hope for significant recovery. The outlook very much depends on the cause of the coma and the ability to correct the particular situation.

How Do People Take Care of Someone in a Coma?

Someone in a coma usually needs to be cared for in the intensive care unit (ICU) of the hospital. There, the person can get extra care and attention from doctors, nurses, and other hospital staff. They make sure the person gets fluids, nutrients, and any medicines needed to keep the body as healthy as possible. These are sometimes given through a tiny plastic tube inserted in a vein or through a feeding tube that brings fluids and nutrients directly to the stomach.

Some comatose people are unable to breathe on their own and need the help of a ventilator (say: ven-tih-lay-ter), a machine that pumps air into the lungs through a tube placed in the windpipe. The hospital staff also tries to prevent bedsores in someone who is comatose. Bedsores are open sores on the body that come from lying in one place for too long without moving at all.

It can be very upsetting and frustrating for a person's family to see someone they love in a coma, and they may feel scared and helpless. But they can help take care of the person. Taking time to visit the hospital and read to, talk to, and even play music for the patient are important because it's possible that the person may be able to hear what's going on, even if he or she can't respond.

What Happens After a Coma?

Usually, a coma does not last more than a few weeks. Sometimes, however, a person stays in a coma for a long time — even years — and will be able to do very little except breathe on his or her own.

Most people do come out of comas, however. Some of them are able to return to the normal lives they had before they got sick. On TV, someone in a coma usually wakes up right away, looks around, and is able to think and talk normally. But in real life, this rarely happens. When coming out of a coma, a person will often be confused and can only slowly respond to what's going on. It will take time for the person to start feeling better.

Whether someone fully returns to normal after being in a coma depends on what caused the coma and how badly the brain may have been hurt. Sometimes people who come out of comas are just as they were before — they can remember what happened to them before the coma and can do everything they used to do. Other people may need therapy to relearn basic things like tying their shoes, eating with a fork or spoon, or learning to walk all over again. They may also have problems with speaking orremembering things.

Over time and with the help of therapists, however, many people who have been in a coma can make a lot of progress. They may not be exactly like they were before the coma, but they can do a lot of things and enjoy life with their family and friends.