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Christopher Evans
Christopher Evans

Coma [EXCLUSIVE]


Coma is a state of prolonged loss of consciousness. It can have a variety of causes, including traumatic head injury, stroke, brain tumor, or drug or alcohol intoxication. A coma may even be caused by an underlying illness, such as diabetes or an infection.




Coma


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Coma is a medical emergency. Quick action is needed to preserve life and brain function. Health care providers typically order a series of blood tests and a brain scan to try to learn what's causing the coma so that proper treatment can begin.


A coma doesn't usually last longer than several weeks. People who are unconscious for a longer time might transition to a lasting vegetative state, known as a persistent vegetative state, or brain death.


A coma is a lengthy deep state of unconsciousness. People in a state of coma are alive but are unable to move or be aware of or respond to their surroundings. They lose their thinking abilities but retain non-cognitive function and normal sleep patterns.


A person may appear fine, but will not able to speak or respond to commands. Spontaneous movements may occur, and the eyes may open in response to external stimuli. Individuals may even occasionally grimace, cry, or laugh. A coma rarely lasts beyond two to four weeks.


However, some people with coma enter a deeper state of unresponsiveness, or a persistent vegetative state, that may remain that way for years or even decades. Some people may face "brain death," in which there is no brain activity and key functions like independent breathing shut down. Removing assistive equipment at this point will lead to death.


Most people with coma eventually regain consciousness and recover gradually. Some individuals never progress beyond very basic responses, but many recover full awareness. Treatment is aimed at preventing pneumonia and physical therapy to prevent permanent muscle contractions and deformities of the bones, joints, and muscles that would limit an individual's recovery. Some people may have a combination of physical, intellectual, and psychological difficulties that need special attention.


A coma is a deep state of unconsciousness. An individual in a coma is alive but unable to move or respond to his or her environment. Coma may occur as a complication of an underlying illness, or as a result of injuries, such as brain injury.


A coma rarely lasts more than 2 to 4 weeks. The outcome for coma depends on the cause, severity, and site of the damage. People may come out of a coma with physical, intellectual, and psychological problems. Some people may remain in a coma for years or even decades. For those people, the most common cause of death is infection, such as pneumonia.


Dr. George A. Harris: Our society faces momentous decisions. Decisions about the right to die. About abortion. About terminal illness, prolonged coma, transplantation. Decisions about life and death. But society isn't deciding. Congress isn't deciding. The courts aren't deciding. Religion isn't deciding. Why? Because society is leaving it up to us, the experts. The doctors.


Consciousness relies on the cerebral hemispheres interacting with an area of the brain stem called the ascending reticular activating system. Injury to these areas causes decreased consciousness or coma. You can contact the Headway helpline to discuss any of the information provided on this page.


There are different levels of coma, ranging from very deep, where the patient shows no response or awareness at all, to shallower levels, where the patient responds to stimulation by movement or opening eyes. Still shallower levels can occur, where the patient is able to make some response to speech. Level of coma is usually initially assessed by the Glasgow Coma Scale (GCS).


The GCS is a very simple, easy to administer technique which is used to rate the severity of coma. It assesses the patient's ability to open their eyes, move and speak. Learn more about the Glasgow Coma Scale.


Recovery from coma is a gradual process, starting with the person's eyes opening, then responding to pain, and then responding to speech. People do not just wake up from a coma, and say, 'Where am I?' as is sometimes portrayed in films. The length of coma is one of the most accurate predictors of the severity of long-term symptoms. The longer the coma, the greater the likelihood of residual symptoms, particularly physical disabilities, although this is only a guide and some people can make good recoveries after an extended period in a coma.


After a coma, during a period known as post-traumatic amnesia (PTA), the patient's behaviour may well be restless, disinhibited and agitated. Uncharacteristic behaviour such as swearing, shouting and inappropriate sexual behaviour are not unusual, but are these are best ignored, as seeing other people's distress may only increase the patient's agitation or distress. An individual cannot be held responsible for their behaviour during this period. This is a difficult time for relatives, but it is important to remember that the patient will come out of it.


This is a condition distinct from coma and vegetative state as the person shows distinct but limited signs awareness and response to stimulation. However, they find it very difficult to remain aware or responsive for any length of time or in a predictable way. People often enter minimally conscious state after being in a vegetative state.


Having a relative in a coma, or some other form of reduced awareness state, is a very distressing and confusing time. It is very important to communicate with the medical staff and to understand as much as possible about the person's level of awareness.


Myxedema coma, the extreme manifestation of hypothyroidism, is an uncommon but potentially lethal condition. Patients with hypothyroidism may exhibit a number of physiologic alterations to compensate for the lack of thyroid hormone. If these homeostatic mechanisms are overwhelmed by factors such as infection, the patient may decompensate into myxedema coma. Patients with hypothyroidism typically have a history of fatigue, weight gain, constipation and cold intolerance. Physicians should include hypothyroidism in the differential diagnosis of every patient with hyponatremia. Patients with suspected myxedema coma should be admitted to an intensive care unit for vigorous pulmonary and cardiovascular support. Most authorities recommend treatment with intravenous levothyroxine (T4) as opposed to intravenous liothyronine (T3). Hydrocortisone should be administered until coexisting adrenal insufficiency is ruled out. Family physicians are in an important position to prevent myxedema coma by maintaining a high level of suspicion for hypothyroidism.


Myxedema coma is an extreme complication of hypothyroidism in which patients exhibit multiple organ abnormalities and progressive mental deterioration. The term myxedema is often used interchangeably with hypothyroidism and myxedema coma. Myxedema also refers to the swelling of the skin and soft tissue that occurs in patients who are hypothyroid. Myxedema coma occurs when the body's compensatory responses to hypothyroidism are overwhelmed by a precipitating factor such as infection.


A common misconception is that a patient must be comatose to be diagnosed with myxedema coma. However, myxedema coma is a misnomer because most patients exhibit neither the nonpitting edema known as myxedema nor coma.1,2 Instead, the cardinal manifestation of myxedema coma is a deterioration of the patient's mental status.


When only comatose patients are considered, myxedema coma is exceedingly rare: one study reports 200 cases between 1953 and 1996.3 Applying a broader definition results in a significantly higher number of cases. While the actual prevalence of myxedema coma is unknown, its lethal nature demands recognition. Even with early detection and appropriate treatment, mortality ranges from 30 to 60 percent.3,4 Family physicians must be alert to the possibility of undiagnosed hypothyroidism in their patients.


Hypothyroidism is four times more common in women than in men; 80 percent of cases of myxedema coma occur in females.5,6 Myxedema coma occurs almost exclusively in persons 60 years and older.5 More than 90 percent of cases occur during the winter months.6 This seasonal presentation is probably due to age-related loss of the ability to sense temperature and lower heat production secondary to hypothyroidism.7


Patients with myxedema coma usually have longstanding hypothyroidism, although it may not have been previously diagnosed. They often demonstrate classic symptoms of hypothyroidism: fatigue; constipation; weight gain; cold intolerance; a deep voice; coarse hair; and dry, pale, cool skin. However, elderly patients with hypothyroidism often have atypical presentations, such as decreased mobility,8 and some patients with compensated hypothyroidism are asymptomatic.9


Physical findings in myxedema coma (Table 2) may include the classic myxedematous face, which is characterized by generalized puffiness, macroglossia, ptosis, periorbital edema, and coarse, sparse hair. Nonpitting edema of the lower extremities is sometimes present. The findings from a thyroid examination are usually normal, but a goiter may be present in some patients. The presence of a scar on the neck might suggest postsurgical hypothyroidism and may be an important clue in the diagnosis of a patient who is comatose. A neurologic examination may reveal decreased reflex tendon relaxation and will invariably reveal altered mentation.


All patients with myxedema coma display deterioration of their mental status. This decline may be subtle, manifesting as apathy, neglect or a decrease in intellectual function; more obvious changes include confusion, psychosis and, rarely, coma. While all patients with myxedema coma present with some degree of mental status change, few progress to coma. When there is doubt about a change in mental status, formal mental status testing should be performed.


Another common clinical feature of myxedema coma is hypothermia. The patient's temperature is usually less than 35.5C (95.9F).13 Conditions that may precipitate myxedema coma such as hypoglycemia and cold exposure may exacerbate the hypothermia. However, the patient's temperature is not always an accurate diagnostic aid because some patients present with a normal temperature. 041b061a72


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