Instructions on how to examine a comatose patient

The first priority before every patient is to ensure the patient's breathing, the airway must be clear. It is necessary to open the mouth and observe the inside to determine the possibility that the patient is comatose due to asphyxiation due to inhaling foreign objects, obstructing viscous sputum, food in the elderly, and limited exercise. At this time, it is necessary to remove the foreign body, remove the viscous sputum and intubate to squeeze the breathing balloon.
The next thing is to ensure effective circulation by taking pulse, measuring blood pressure. If the circulatory ability is inhibited such as loss of pulse, hypotension, it is necessary to replace the fluid, use vasopressors in parallel with chest compressions to reestablish artificial circulation for the patient.
In addition, it is necessary to test blood glucose locally in patients receiving antidiabetic therapy or in elderly and frail patients with poor diet to compensate for intravenous glucose if hypoglycaemia is present. At the same time, it is necessary to do a general examination, look for injuries and bleeding sources to fix, stop bleeding, and limit causing further trauma during resuscitation and movement.
At the same time, another health care worker should ask for the history and medical history from the patient's next of kin or eyewitness to the loss of consciousness. As more clinical data are gathered, the differential diagnoses are narrowed, and the likelihood of correct treatment and success rates increases.

In clinical practice, there are many different methods to assess the degree of coma, from the qualitative classification to the application of cognitive evaluation scales in each different situation.
How to classify the degree of qualitative loss of consciousness: from somnolence, somnolence, true coma and vegetative state.
How to classify the degree of coma into three stages I, II and III: from the time when the patient is still able to respond with speech, pronunciation, and movement until the patient completely no longer has any ability to respond. responsiveness to auditory or painful stimuli.
Glasgow scale to assess coma: allows detailed assessment in many aspects such as eyes, speech and movement, limiting the disadvantage of depending on the subjective feelings of the examiner. This scale has a maximum score of 15 and the lowest possible score is 3. The overall result of the Glasgow scale helps to classify the degree of coma due to brain injury, the lower the score, the worse the prognosis.
In addition, there are a number of other scales that also help classify the degree of coma in a specific way such as the coma scale for children, the Liege scale with additional points on brain stem reflexes, the rating scale coma according to the structural layer of the central nervous system...

The patient's breathing pattern or respiratory cycle helps to provide more information about the extent of the injury and the cause of the coma:
Cheyne-Stokes breathing: a breathing pattern with a rate that gradually increases and then slows down and there is a pause in breathing until re-triggering a new breathing cycle that begins to accelerate. The cause is usually damage to both hemispheres. Central nervous system hyperventilation: breathing that is both rapid in frequency and deep in amplitude. It is caused by damage to the brain stem between the midbrain and pons. In the case of pontine damage, the patient breathes with a prolonged period of inspiration, then stops breathing for a short time before exhaling.
Ataxia breathing: is breathing pattern with irregular amplitude and frequency. The cause is damage to the medulla oblongata and is often seen in dying patients.
Coma with hyperventilation: due to metabolic disorders such as diabetes, hepatic encephalopathy, uremia, salicylate poisoning...
Coma due to hypoventilation: due to overdose of sedatives or in other medical conditions. case of chronic obstructive pulmonary disease.

Examination of the cranial nerves is objective examination, based on the integrity of these reflex arcs.
Examination of the pupil: observe the size, compare the two sides and assess the response to light stimulation. This is an important factor to help distinguish between the two groups of causes of coma due to metabolic disorders or structural lesions.
Accordingly, in the case of a patient who is in a deep coma while the pupillary functions are still intact, the possibility is due to metabolism and the prognosis is still better than in the case of patients with only mild cognitive disturbances but dilated symptoms appear. pupil on one side.
Corneal reflex: The entrance is the V cranial nerve and the exit is the VII nerve. The reflex is also when touching the cornea and the patient still responds by blinking. Eyeball reflex, doll eye reflex: observe how the eyeball moves while combined with head rotation. Vomiting reflex: used to assess the function of cranial nerves IX and X. However, it is not recommended because patients with impaired consciousness are no longer able to protect the airway and are at risk of aspiration.

Because a comatose patient will have reduced or no ability to follow medical orders, the primary function of mobility testing is to see if the patient is able to move spontaneously in response to verbal or painful stimuli. no, is there bilateral symmetry or purposeful movements.
Besides, the assessment of muscle tone is also necessary. Patients often have hypotonia in cases of metabolic coma, and hypertonia if neurologic deficits occur.
In addition, the doctor also needs to look for abnormal movements such as cortical or cerebral spasticity, muscle convulsions.

The general examination of the organ systems to have a comprehensive assessment, avoid missing signs suggestive of the cause of the coma. The general examination includes:
Look for signs suggesting head trauma, contusion, bleeding, scratches...
Pale skin color suggests coma due to respiratory failure, circulatory collapse; Bright red skin color suggests coma due to carbon dioxide poisoning. Pale skin color, pale mucous membranes suggest the possibility of severe acute anemia due to accident, internal trauma.
Look for signs of liver failure such as jaundice, yellow eyes, hepatomegaly, ascites, leg edema.
Fruity breath suggests the patient is comatose after alcohol poisoning, ketosis in the setting of diabetes.
Bites on lips, tongue can be caused by seizures in epileptic state.
Find meningeal signs

Tests that need to be done quickly include local capillary blood sugar, complete blood count, electrolytes with both magnesium and calcium ions, liver function, kidney function, thyroid function, adrenal hormone kidney and suspected toxicants. At the same time, toxic substances can also be found in the urine test.
If the patient has a history of using psychotropic drugs, antidepressants, anticonvulsants, these drugs should be measured in blood or urine.
A cranial imaging tool to help quickly find internal structural lesions such as ischemic stroke or cerebral hemorrhage, brain contusion or hematoma causing compression, brain herniation. Simultaneously, a lumbar puncture should be performed if the possibility of subarachnoid hemorrhage cannot be excluded on computed tomography or the patient is suspected of encephalitis or meningitis.
EEG also helps to differentiate nonconvulsive status epilepticus or requires confirmation of brain death.
In short, examining a comatose patient is not merely a medical skill but also an "art", which depends a lot on the experience and sensitivity of the doctor. However, in emergency situations, the patient's life is the important goal and then, the examination to determine the cause of the coma, the appropriate treatment will help improve the long-term outcome.
Vinmec International General Hospital is one of the hospitals that not only ensures professional quality with a team of leading medical doctors, modern equipment and technology, but also stands out for its examination and consultation services. comprehensive and professional medical consultation and treatment; civilized, polite, safe and sterile medical examination and treatment space.
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