II. Background: Key goal of Coma Exam is distinguish cause

  1. Toxic or metabolic cause
  2. Structural cause

III. Exam: Vital Signs

IV. Exam: General

  1. Breath (also see Toxin Induced Odors)
    1. Alcohol
    2. Fruity breath (Diabetes Mellitus)
    3. Almonds (Cyanide toxicity)
    4. Insecticides (Organophosphate Toxicity)
  2. Head Trauma signs
    1. Hemotympanum
    2. Cephalohematoma
    3. CSF leakage from nares or ear canal
  3. Neck
    1. Meningismus
    2. Thyromegaly
  4. Cardiopulmonary exam
    1. Pulmonary Rales or Wheezes
    2. Chest Scars
    3. Cardiac Murmurs
    4. Irregular rhythm (Atrial Fibrillation)
    5. Breathing pattern (e.g. Cheyne-Stokes Respiration)
  5. Abdomen
    1. Bowel sounds
    2. Ascites or Hepatomegaly (Hepatic Encephalopathy)
    3. Abdominal Aortic Aneurysm
  6. Skin
    1. Jaundice
    2. Needle Tracks (Intravenous Drug Abuse)
    3. Petechiae
    4. Skin Temperature
    5. Hydration

V. Exam: Neurologic

  1. Brainstem Reflexes
    1. Eye Neurologic Exam
    2. Oculocephalic Reflex (Doll's Eyes)
      1. Normal: Eyes move to maintain focus despite head position change
      2. Brainstem Injury: Eyes remain fixed in orbits and do not maintain focus
    3. Oculovestibular Testing (Cold Calorics)
      1. Cold water instilled into ear results in Nystagmus (slow toward cold water, rapid away to side)
    4. Glasgow Coma Scale
    5. FOUR Score Coma Exam (Full Outline of Unresponsiveness)
  2. Autisms (Involuntary protective-type acts)
    1. Yawning
    2. Hiccups
    3. Sneezing
    4. Swallowing
  3. Motor Testing
    1. Observe at rest
      1. Spontaneous movements
      2. Posturing
    2. Purposeful movement (e.g. response to pain)
      1. Indicates intact Brainstem
      2. Indicates intact cortex
    3. Response to painful stimuli
      1. Abduction or adduction
      2. Posturing
        1. Decorticate Posturing
        2. Decerebrate Posturing
      3. Triple flexion response (spinal reflex)
      4. Asymmetric response
      5. Flaccid Paralysis

VI. References

  1. Orman and Chang in Herbert (2017) EM:Rap 17(4): 8-9

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