II. Background: Key goal of Coma Exam is distinguish cause
- Toxic or metabolic cause
- Structural cause
III. Exam: Vital Signs
-
Hyperventilation
- Consider underlying Metabolic Acidosis or Hypoxemia
- Abnormal Pulse
- Abnormal Blood Pressure
- Rectal Temperature
IV. Exam: General
- Breath (also see Toxin Induced Odors)
- Alcohol
- Fruity breath (Diabetes Mellitus)
- Almonds (Cyanide toxicity)
- Insecticides (Organophosphate Toxicity)
-
Head Trauma signs
- Hemotympanum
- Cephalohematoma
- CSF Leakage from nares or ear canal
- Neck
- Meningismus
- Thyromegaly
- Cardiopulmonary exam
- Pulmonary Rales or Wheezes
- Chest Scars
- Cardiac Murmurs
- Irregular rhythm (Atrial Fibrillation)
- Breathing pattern (e.g. Cheyne-Stokes Respiration)
- Abdomen
- Skin
- Jaundice
- Needle Tracks (Intravenous Drug Abuse)
- Petechiae
- Skin Temperature
- Hydration
V. Exam: Neurologic
-
Brainstem Reflexes
- Eye Neurologic Exam
- Oculocephalic Reflex (Doll's Eyes)
- Normal: Eyes move to maintain focus despite head position change
- Brainstem Injury: Eyes remain fixed in orbits and do not maintain focus
- Oculovestibular Testing (Cold Calorics)
- Cold water instilled into ear results in Nystagmus (slow toward cold water, rapid away to side)
- Glasgow Coma Scale
- FOUR Score Coma Exam (Full Outline of Unresponsiveness)
-
Autisms (Involuntary protective-type acts)
- Yawning
- Hiccups
- Sneezing
- Swallowing
- Motor Testing
- Observe at rest
- Spontaneous movements
- Posturing
- Purposeful movement (e.g. response to pain)
- Indicates intact Brainstem
- Indicates intact cortex
- Response to painful stimuli
- Abduction or adduction
- Posturing
- Triple flexion response (spinal reflex)
- Asymmetric response
- Flaccid Paralysis
- Observe at rest
VI. References
- Orman and Chang in Herbert (2017) EM:Rap 17(4): 8-9