Coma

Overview

• Coma is different from sleep because the person is unable to wake up.
• Moreover, It is not the same as brain death. The person is alive, but they cannot respond in the normal way to their environment.
• Whether or not they are conscious, or how many people are conscious during a coma, or the level of consciousness, is a question that scientists are currently investigating.
• Levels of consciousness also responsiveness will depend on how much of the brain is functioning.
• A coma often lasts for a few days or weeks. occasionally, it can last for several years.

Medical Emergency

• In general, If a person enters a coma, this is a medical emergency.
• Rapid action may be needed to preserve life also brain function.
• They do not respond to pain, either light, or sound in the usual way, and they do not make voluntary actions.
• Although they do not wake up, their body follows normal sleep patterns.
• Automatic functions, for example, breathing and circulation, normally continue to function, but the person’s thinking ability is suppressed.
• According to the National Institutes of Neurological Disorders and Stroke (in other words, NINDS), the person may sometimes grimace, laugh, or cry as a reflex. [2]

Epidemiology 

Causes 

Many types of problems can cause coma. Some examples are:

Traumatic brain injuries:

• Road traffic accidents, sports injuries, also violent attacks that involve a blow to the head can cause coma. [2]
• When the brain swells as a result of trauma, the fluid pushes up against the skull.
• The swelling may eventually cause the brain to push down on the brain stem, which can damage the RAS (Reticular Activating System) a part of the brain that’s responsible for arousal and awareness. [3]

Stroke:

• Reduced or interrupted blood supply to the brain (i.e. stroke), which may be caused by blocked arteries or a burst blood vessel, can result in a coma.

Tumors:

• Tumors either in the brain or brain stem can cause a coma. [1]

Diabetes:

• In people with diabetes, blood sugar levels that become too high (hyperglycemia) or too low (hypoglycemia) can cause a coma. [1]
• This type of coma is usually reversible once the blood sugar is corrected. [3]

Lack of oxygen:

• Oxygen is essential for brain function.
• Cardiac arrest causes a sudden cut off of blood flow and oxygen to the brain, called hypoxia or anoxia.
• After cardiopulmonary resuscitation (in other words, CPR), survivors of cardiac arrest are often in comas.
• Oxygen deprivation can also occur with drowning or choking. [3]

Infections:

• Infections such as encephalitis and meningitis cause swelling (in other words, inflammation) of the brain, spinal cord or the tissues that surround the brain.
• Severe cases of these infections can result in either brain damage or a coma. [1]

Bleeding:

• Bleeding in the layers of the brain may cause coma due to swelling and compression on the injured side of the brain.
• This compression causes the brain to shift, causing damage to the brain stem also the RAS.
• High blood pressure, cerebral aneurysms, also tumors are non-traumatic causes of bleeding in the brain. [3]

Seizures:

• A single seizure rarely produces coma. But continuous seizures  called status epilepticus  can produce coma.
• Repeated seizures can prevent the brain from recovering in between seizures.
• This will cause prolonged unconsciousness also coma. [3]

Toxins:

• Substances that are normally found in the body can accumulate to toxic levels if the body fails to dispose of them correctly.
• As an example, ammonia due to liver disease, carbon dioxide from a severe asthma attack, or urea from kidney failure can accumulate to toxic levels in the body.

Drugs and alcohol:

• Drugs and alcohol in large quantities can also disrupt neuron functioning in the brain. [3]

Types of coma

• Toxic-metabolic encephalopathy- This is an acute condition of brain dysfunction with symptoms of confusion and/or delirium. The condition is usually reversible. The causes of toxic-metabolic encephalopathy are varied. They include systemic illness, infection, organ failure, and other conditions.
• Persistent vegetative state- This is a state of severe unconsciousness. The person is unaware of their surroundings and incapable of voluntary movement. With a persistent vegetative state, someone may progress to wakefulness but with no higher brain function. With persistent vegetative state, there is breathing, circulation, and sleep-wake cycles.
• Medically induced: This type of temporary coma, or deep state of unconsciousness, is used to protect the brain from swelling after an injury – and allow the body to heal. The patient receives a controlled dose of an anesthetic, which causes lack of feeling or awareness. Doctors then closely watch the person’s vitals. This happens only in hospital intensive care units.(7)

Risk factor of Coma

• A hemorrhagic or ischemic stroke
• A severe head injury
• Seizures
• Brain tumor
• Brain infections
• Hypoxia for a long time
• Metabolic abnormalities, such as diabetic hyperosmolar coma, hypoglycemia
• Toxins, including poisons, alcohol and other drugs (barbiturates, sedatives, amphetamines,cocaine)
• Liver failure or kidney failure (6)

Pathogenesis

Pathophysiology of Coma

• The accepted pathophysiology of a coma involves neuronal dysfunction from a decrease in the supply of glucose or oxygen to the brain.
• A myriad of etiologies may lead to essential substrate disruption with diffuse central nervous system (CNS) dysfunction and coma as the extreme clinical condition.(8)

Clinical Features 

Sign & Symptoms 

The signs and symptoms of a coma commonly i.e.:

• Closed eyes
• Depressed brain stem reflexes, such as pupils not responding to light
• Furthermore, No responses of limbs, except for reflex movements
• Besides this, No response to painful stimuli, except for reflex movements
• Irregular breathing [1]

Before entering a coma, a person with worsening hypoglycemia (low blood sugar), or hypercapnia (higher blood CO2 levels), for example, will first experience mild agitation.

Without treatment, their ability to think clearly will gradually decrease.

Finally, they will lose consciousness. [2]

Clinical examination of Coma

• The severity of coma impairment is categorized into several levels. Patients may or may not progress through these levels. In the first level, the brain responsiveness lessens, normal reflexes are lost, the patient no longer responds to pain and cannot hear.
• Contrary to popular belief, a patient in a coma does not always lie still and quiet. They may move, talk, and perform other functions that may sometimes appear to be conscious acts but are not.
• Two scales of measurement often used in TBI diagnosis to determine the level of coma are the Glasgow Coma Scale (GCS) and the Ranchos Los Amigos Scale(RLAS).
• The GCS is a simple 3 to 15-point scale (3 being the worst and 15 being that of a typical person) used by medical professionals to assess severity of neurologic trauma, and establish a prognosis.
• The RLAS is a more complex scale that has eight separate levels, and is often used in the first few weeks or months of coma while the patient is under closer observation, and when shifts between levels are more frequent.(6)

Diagnosis 

A medical and recent history, blood tests, physical tests, also imaging scans can help find out the cause of a coma, also this helps decide which treatment to apply.

Medical history:

Friends, family, police, and witnesses, if appropriate, may be asked:

• Whether the coma or symptoms beforehand started either slowly or suddenly
• If the person had or appeared to have any vision problems, dizziness, stupor or numbness before the coma
• Whether the patient has diabetes, any history of seizures or stroke, or any other condition or disease
• What medications or other substances the patient may have been taken

Physical tests i.e.:

• Generally, the aim is to check the person’s reflexes, how they respond to pain, also their pupil size.
• Tests may involve squirting either very cold or warm water into the ear canals.
• These tests will trigger varying reflexive eye movements.
• The type of response varies according to the cause of the coma.

Blood tests:

These will be taken to determine i.e.:

• Blood count
• Signs of carbon monoxide poisoning
• Presence and levels of either legal or illegal drugs or other substances
• Levels of electrolytes
• Glucose levels
• Liver function

Lumbar puncture (in other words, spinal tap):

This can check for any infection or disorder of the CNS.

The doctor inserts a needle into the patient’s spinal canal, measures pressure, also extracts fluid to send for tests.

Imaging scans of the brain:

• These will help determine whether there is any either brain injury or damage, and where.
• A CT or CAT scan or an MRI will check for blockages or other abnormalities.
• An electroencephalography (in other words, EEG) will measure electrical activity within the brain.

Glasgow Coma Scale:

• The scale is used as part of the initial evaluation of a patient, but does not assist in making the diagnosis as to the cause of coma.
• Since it "scores" the level of coma, the GCS can be used as a standard method for any health-caregiver to assess change in patient status. [4]
• The Glasgow Coma Scale (in other words, GCS) can be used to assess the severity of brain damage following a head injury.
• It gives patients a score, according to verbal responses, physical responses, also how easily they can open their eyes.

[4]

Differential diagnosis of Coma

• Structural abnormality
• Seizure
• Encephalitis
• Metabolic derangements
• Toxicologic etiologies.(9)

Complications 

Investigations 

Blood tests:

These will be taken to determine i.e.:

• Blood count
• Signs of carbon monoxide poisoning
• Presence and levels of either legal or illegal drugs or other substances
• Levels of electrolytes
• Glucose levels
• Liver function

Lumbar puncture (in other words, spinal tap):

This can check for any infection or disorder of the CNS.

The doctor inserts a needle into the patient’s spinal canal, measures pressure, also extracts fluid to send for tests.

Imaging scans of the brain:

• These will help determine whether there is any either brain injury or damage, and where.
• A CT or CAT scan or an MRI will check for blockages or other abnormalities.
• An electroencephalography (in other words, EEG) will measure electrical activity within the brain.

Glasgow Coma Scale:

• The scale is used as part of the initial evaluation of a patient, but does not assist in making the diagnosis as to the cause of coma.
• Since it "scores" the level of coma, the GCS can be used as a standard method for any health-caregiver to assess change in patient status. [4]
• The Glasgow Coma Scale (in other words, GCS) can be used to assess the severity of brain damage following a head injury.
• It gives patients a score, according to verbal responses, physical responses, also how easily they can open their eyes.

Treatment of Coma

• Treatment for a coma depends on the cause.
• Moreover, People close to the comatose patient should give doctors as much information as possible to help the doctors determine the cause of coma.
• Prompt medical attention is vital to treat potentially reversible conditions.
• For example, if there is an infection that’s affecting the brain, antibiotics may be needed.
• Glucose may be required in the event of a diabetic shock.
• Surgery may also be necessary to relieve the pressure on the brain due to swelling or to remove a tumor.
• Certain drugs may also help relieve the swelling.
• Medication may also be given to stop seizures if necessary.
• In general, treatment for a coma is supportive.
• People in comas are looked after in an intensive care unit and may often require full life support until their situation improves. [3]
• For patients in a prolonged coma, or persistent vegetative state, the focus is on preventing infections, providing nutrition, also maintaining the patient’s physical health.
• This includes proper nutrition and prevention of infections such as pneumonia (a common cause of death in those in a long-term coma) also bedsores.
• Sometimes, physical therapy is administered to prevent bone, joint, or muscle deformities.

Prevention of Coma

• Proper blood glucose management.
• Sticking to your diet
• Regular exercise
• Moderating alcohol and eating when drinking alcohol
• Staying hydrated, preferably with water (10)

Homeopathic Treatment of Coma

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines for Coma:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Homeopathic remedies for coma due to acute head injury:

• Generally, Immediately after a severe head injury, the focus should be on life-saving emergency care.
• Even at this time homeopathic medicines are important in stimulating recovery.
• The sooner these medicines are given the better.
• Then, depending on response I will change remedy or potency or frequency of repetition.
• Generally, Aconite is indicated within the first few minutes or hours after injury, where the person is restless and terrified, even panic-stricken, by the fear of imminent death.
• Those needing Arnica generally, deny that they need any help, saying that they feel quite well. Additionally, they may be severely bruised.
• Besides this, Opium is valuable for someone who is in a daze or even a coma after the head injury, with a flushed and bloated-look­ing face. Lastly, They may have severe injuries elsewhere, yet not complain of pain.

Homeopathic remedies for coma due to chronic head injury:

The following remedies can be valuable in many of those suffering from the long-term consequences of head injuries.

Natrum sulphuricum:

• It will be in indicated in those with persistent emotional and personality changes, in particular irritability also depression.
• These may be so severe that the person feels suicidal.
• There may be ringing in the ears, as well as vertigo.
• All the symptoms will be worse in damp, wet weather.

Natrum muriaticum:

• This may be valuable in those who after a head injury become sad also withdrawn.
• They may also have chronic headaches that are worse in direct sunlight and develop a marked craving for or dislike of salt.
• When they are at the seaside the symptoms may change, becoming dramatically worse or better.

Hyoscymus Niger:

• It is helpful when there is a change in behaviour, with the person becoming more talkative and excitable.
• Signs of dis inhibition such as laughing inappropriately or handling their genitals may be present.
• Epilepsy, twitches, muscle spasms, hiccoughs, and unusual repetitive gestures, such as picking at their clothes, may also be a problem.

Helleborus:

• This should be thought of when the person seems more dull or slowed since the head injury.
• The person almost seems shut off from the world, with eyes “that do not see” and ears “that do not hear”.
• They may seem almost indifferent to either pain or pleasure.

Hypericum:

• It is indicated when the person has convulsions soon after the injury.
• There may also be spinal injury.
• Later on the person may complain of nerve pain or pins also needles. [5]

Diet & Regimen of Coma

• Eat modest portions. Eating large portions is linked to sleepiness, so keep portions moderate and be mindful of your fullness levels.
• Choose balanced meals.
• Limit alcohol intake.
• Stay hydrated.
• Get a good night’s sleep.
• Use bright light.
• Take a nap.
• Drink water and non-caffeinated tea.
• Do some aerobic exercise.
• Eat smaller meals for the rest of the day.
• Also eat some probiotics.
• Eat carbs that are low on the glycemic index. (11)

Do’s & Don’ts

Terminology

References 

1. https://www.mayoclinic.org/diseases-conditions/coma/diagnosis-treatment/drc-20371103
2. https://www.medicalnewstoday.com/articles/173655.php
3. https://www.webmd.com/brain/coma-types-causes-treatments-prognosis#1-2
4. https://www.emedicinehealth.com/coma/article_em.htm#what_is_the_glasgow_coma_scale
5. https://www.britishhomeopathic.org/charity/how-we-can-help/articles/conditions/h/a-little-bump-or-a-major-injury/
6. examination
7. https://www.webmd.com/brain/coma-types-causes-treatments prognosis#091e9c5e8027d4dc-2-3
8. https://www.google.com/search?q=pathophysiology++of+coma&newwindow
9. https://www.google.com/search?q=differntial+diagnosis+of+coma&newwindow
10. https://www.healthline.com/health/understanding-and-preventing-diabetic-coma#prevention
11. https://www.healthline.com/nutrition/food-coma
12. National Survey on Coma Epidemiology, Evaluation, and Therapy in India.
13. the Indian Journal of Critical Care Medicine titled "The Curing Coma Campaign®".
14. "Plum and Posner’s Diagnosis and Treatment of Stupor and Coma" (Fourth Edition, Jerome B. Posner, Fred Plum, Nicholas J. Schiff, 2007, Oxford University Press).
15. "Adams and Victor’s Principles of Neurology" (11th Edition, Allan H. Ropper, Martin A. Samuels, Joshua P. Klein, 2019, McGraw Hill Professional).
16. "Critical Care Medicine: Principles of Diagnosis and Management in the Adult" (Fourth Edition, Joseph E. Parrillo, R. Phillip Dellinger, 2008, Elsevier Saunders).
17. "Critical Care Medicine: Principles of Diagnosis and Management in the Adult" (Fourth Edition, Joseph E. Parrillo, R. Phillip Dellinger, 2008, Elsevier Saunders).

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