Clinical approach to coma patients: tips and tricks

The reticular activating system (RAS) is responsible for wakefulness. The RAS projects activation to either side of the hemisphere. The dysfunction of the RAS or insufficiency of its activation results in impairment of consciousness. Physicians classify levels of awareness into four levels, from normal status to most severe unconsciousness, these being alert, drowsy, stupor, and coma, respectively. While the causes of unconsciousness are varied, physicians generally divide them into structural and metabolic etiologies upon the dominant approach. Surgical management is the primary treatment for the structural coma, while the metabolic coma requires predominantly medical treatment. The diagnosis and management of unconscious patients require extensive clinical assessment, consisting of a careful approach to history-taking and general medical and neurological examinations. Following immediate resuscitation by the ABCDE approach and proper management protocols, physicians should look for causes of loss of consciousness through clinical evidence and investigations. Appropriate management will help to avoid secondary complications related to the impairment of consciousness. The prognostication of a coma is also varied and primarily depends on its etiology. The algorithm for prognostication in a coma is helpful for poor outcome determinants.