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69-466: Clinically, a coma can be defined as the consistent inability to follow a one-step command. It can also be defined as having a score of 8 or less on the Glasgow Coma Scale (GCS) for at least 6 hours. For a patient to maintain consciousness, the components of wakefulness and awareness must be maintained. Wakefulness is a quantitative assessment of the degree of consciousness , whereas awareness

138-448: A blockage in neural transmission. While a diffuse cause is limited to aberrations of cellular function, that fall under a metabolic or toxic subgroup. Toxin-induced comas are caused by extrinsic substances, whereas metabolic-induced comas are caused by intrinsic processes, such as body thermoregulation or ionic imbalances (e.g. sodium). For instance, severe hypoglycemia (low blood sugar) or hypercapnia (increased carbon dioxide levels in

207-519: A car accident) and also to monitor hospitalised patients and track their level of consciousness. Lower GCS scores are correlated with higher risk of death. However, the GCS score alone should not be used on its own to predict the outcome for an individual person with brain injury. The Glasgow Coma Scale is used for people above the age of two and is composed of three tests: eye , verbal , and motor responses. The scores for each of these tests are indicated in

276-468: A coma after long periods of time. After 19 years in a minimally conscious state , Terry Wallis spontaneously began speaking and regained awareness of his surroundings. A man with brain damage and trapped in a coma-like state for six years was brought back to consciousness in 2003 by doctors who planted electrodes deep inside his brain. The method, called deep brain stimulation (DBS), successfully roused communication, complex movement and eating ability in

345-584: A coma with a combination of physical, intellectual, and psychological difficulties that need special attention. It is common for coma patients to awaken in a profound state of confusion and experience dysarthria , the inability to articulate any speech. Recovery is usually gradual. In the first days, the patient may only awaken for a few minutes, with increased duration of wakefulness as their recovery progresses, and they may eventually recover full awareness. That said, some patients may never progress beyond very basic responses. There are reports of people coming out of

414-600: A comatose state. Heart-related causes of coma include cardiac arrest , ventricular fibrillation , ventricular tachycardia , atrial fibrillation , myocardial infarction , heart failure , arrhythmia when severe, cardiogenic shock , myocarditis , and pericarditis . Respiratory arrest is the only lung condition to cause coma, but many different lung conditions can cause decreased level of consciousness , but do not reach coma. Other causes of coma include severe or persistent seizures , kidney failure , liver failure , hyperglycemia , hypoglycemia , and infections involving

483-1112: A concern that patients were not being assessed or medically managed correctly. Appropriate assessment is a critical step in medical management for several reasons. First, a reliable assessment allows doctors to provide the appropriate treatment. Second, assessments let doctors keep track of how a patient is doing, and intervene if the patient is doing worse. Finally, a system of assessment allows researchers to define categories of patients. This makes it possible to determine which treatments are best for different types of patients. A number of assessments for head injury ("coma scales") were developed, though none were widely adopted. Of 13 scales that had been published by 1974, all involved linear scales that defined levels of consciousness. These scales posed two problems. First, levels of consciousness in these scales were often poorly defined. This made it difficult for doctors and nurses to evaluate head injury patients. Second, different scales used overlapping and obscure terms that made communication difficult. In this setting, Bryan Jennett and Graham Teasdale of

552-487: A great deal of oxygen for its neurons . Oxygen deprivation in the brain , also known as hypoxia , causes sodium and calcium from outside of the neurons to decrease and intracellular calcium to increase, which harms neuron communication. Lack of oxygen in the brain also causes ATP exhaustion and cellular breakdown from cytoskeleton damage and nitric oxide production. Twenty percent of comatose states result from an ischemic stroke, brain hemorrhage, or brain tumor. During

621-455: A leading figure in neurological trauma, wrote an editorial in Journal of Neurosurgery strongly encouraging neurosurgical units to adopt the GCS score. Second, the GCS was included in the first version of Advanced Trauma Life Support (ATLS), which expanded the number of centres where staff were trained in performing the GCS. The GCS has come under pressure from some researchers who take issue with

690-410: A lesion (a point of damage) at or above the red nucleus , whereas a decerebrate posturing indicates a lesion at or below the red nucleus. In other words, a decorticate lesion is closer to the cortex , as opposed to a decerebrate posturing which indicates that the lesion is closer to the brainstem . Pupil assessment is often a critical portion of a comatose examination, as it can give information as to

759-459: A metabolic source of ammonium, is restricted, and caloric intake is provided by glucose and fat. Intravenous arginine ( argininosuccinase deficiency ), sodium phenylbutyrate and sodium benzoate (ornithine transcarbamylase deficiency) are pharmacologic agents commonly used as adjunctive therapy to treat hyperammonemia in patients with urea cycle enzyme deficiencies. Sodium phenylbutyrate and sodium benzoate can serve as alternatives to urea for

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828-412: A particular domain, or greatly increases the likelihood of life improvement enabling the subject to realize some good. That said, sensitivity to reward signals is a fundamental element in the learning process, both consciously and unconsciously. Moreover, the unconscious brain is able to interact with its surroundings in a meaningful way and to produce meaningful information processing of stimuli coming from

897-568: A patient possibly in a coma: In the initial assessment of coma, it is common to gauge the level of consciousness on the AVPU (alert, vocal stimuli, painful stimuli, unresponsive) scale by spontaneously exhibiting actions and, assessing the patient's response to vocal and painful stimuli. More elaborate scales, such as the Glasgow Coma Scale , quantify an individual's reactions such as eye opening, movement and verbal response in order to indicate their extent of brain injury. The patient's score can vary from

966-401: A patient with a head injury. Their work resulted in the 1974 publication of the first iteration of the GCS. The original scale involved three exam components (eye movement, motor control, and verbal control). These components were scored based on clearly defined behavioural responses. Clear instructions for administering the scale and interpreting results were also included. The original scale

1035-501: A person in a comatose state are: Many types of problems can cause a coma. Forty percent of comatose states result from drug poisoning . Certain drug use under certain conditions can damage or weaken the synaptic functioning in the ascending reticular activating system (ARAS) and keep the system from properly functioning to arouse the brain. Secondary effects of drugs, which include abnormal heart rate and blood pressure, as well as abnormal breathing and sweating, may also indirectly harm

1104-417: A person's level of consciousness after a brain injury . The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These three behaviours make up the three elements of the scale: eye, verbal, and motor. A person's GCS score can range from 3 (completely unresponsive) to 15 (responsive). This score is used to guide immediate medical care after a brain injury (such as

1173-523: A result of being confined to a bed. Moving patients through the use of physical therapy also aids in preventing atelectasis , contractures or other orthopedic deformities which would interfere with a coma patient's recovery. Pneumonia is also common in coma patients due to their inability to swallow which can then lead to aspiration . A coma patient's lack of a gag reflex and use of a feeding tube can result in food, drink or other solid organic matter being lodged within their lower respiratory tract (from

1242-421: A result, a version for children has been developed, and is outlined below. Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35". Patients with scores of 3 to 8 are usually considered to be in a coma. Generally, brain injury is classified as: Tracheal intubation and severe facial/eye swelling or damage make it impossible to test

1311-460: A result, the six-point motor scale is now considered the standard. Teasdale did not originally intend to use the sum score of the GCS components. However, later work demonstrated that the sum of the GCS components, or the Glasgow Coma Score, had clinical significance. Specifically, the sum score was correlated with outcome (including death and disability). As a result, the Glasgow Coma Score

1380-530: A score of 3 (indicating severe brain injury and death) to 15 (indicating mild or no brain injury). In those with deep unconsciousness, there is a risk of asphyxiation as the control over the muscles in the face and throat is diminished. As a result, those presenting to a hospital with coma are typically assessed for this risk (" airway management "). If the risk of asphyxiation is deemed high, doctors may use various devices (such as an oropharyngeal airway , nasopharyngeal airway or endotracheal tube ) to safeguard

1449-792: A stroke, blood flow to part of the brain is restricted or blocked. An ischemic stroke , brain hemorrhage , or brain tumor may cause restriction of blood flow. Lack of blood to cells in the brain prevents oxygen from getting to the neurons, and consequently causes cells to become disrupted and die. As brain cells die, brain tissue continues to deteriorate, which may affect the functioning of the ARAS, causing unconsciousness and coma. Comatose cases can also result from traumatic brain injury , excessive blood loss , malnutrition , hypothermia , hyperthermia , hyperammonemia , abnormal glucose levels, and many other biological disorders. Furthermore, studies show that 1 out of 8 patients with traumatic brain injury experience

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1518-642: A structure in the brainstem . The term 'coma', from the Greek κῶμα koma , meaning deep sleep, had already been used in the Hippocratic corpus ( Epidemica ) and later by Galen (second century AD). Subsequently, it was hardly used in the known literature up to the middle of the 17th century. The term is found again in Thomas Willis ' (1621–1675) influential De anima brutorum (1672), where lethargy (pathological sleep), 'coma' (heavy sleeping), carus (deprivation of

1587-486: Is a metabolic disturbance characterised by an excess of ammonia in the blood . Severe hyperammonemia is a dangerous condition that may lead to brain injury and death . It may be primary or secondary. Ammonia is a substance that contains nitrogen . It is a product of the catabolism of protein . It is converted to the less toxic substance urea prior to excretion in urine by the kidneys . The metabolic pathways that synthesize urea involve reactions that start in

1656-435: Is a qualitative assessment of the functions mediated by the cortex, including cognitive abilities such as attention, sensory perception, explicit memory, language, the execution of tasks, temporal and spatial orientation and reality judgment. Neurologically, consciousness is maintained by the activation of the cerebral cortex —the gray matter that forms the brain's outermost layer—and by the reticular activating system (RAS),

1725-437: Is a stereotypical posturing in which the patient has arms flexed at the elbow, and arms adducted toward the body, with both legs extended . Decerebrate posturing is a stereotypical posturing in which the legs are similarly extended (stretched), but the arms are also stretched (extended at the elbow). The posturing is critical since it indicates where the damage is in the central nervous system. A decorticate posturing indicates

1794-503: Is an important part of the physical exam. Due to the unconscious status of the patient, only a limited number of the nerves can be assessed. These include the cranial nerves number 2 (CN II), number 3 (CN III), number 5 (CN V), number 7 (CN VII), and cranial nerves 9 and 10 (CN IX, CN X). Assessment of posture and physique is the next step. It involves general observation about the patient's positioning. There are often two stereotypical postures seen in comatose patients. Decorticate posturing

1863-412: Is associated with 5- to 10-fold higher risk of irreversible brain damage . Hyperammonemia is one of the metabolic derangements that contribute to hepatic encephalopathy , which can cause swelling of astrocytes and stimulation of NMDA receptors in the brain. The following list includes such examples: Treatment centres on limiting intake of ammonia and increasing its excretion. Dietary protein ,

1932-458: Is available under the trade name Ammonul . Acidification of the intestinal lumen using lactulose can decrease ammonia levels by protonating ammonia and trapping it in the stool. This is a treatment for hepatic encephalopathy. Treatment of severe hyperammonemia (serum ammonia levels greater than 1000 μmol/L ) should begin with hemodialysis if it is otherwise medically appropriate and tolerated. Continuous renal replacement therapy (CRRT)

2001-418: Is good if the subject has the capacity for relationship with others, i.e. for meaningfully interacting with other people." This suggests that unawareness may (at least partly) fulfill both conditions identified by Hawkins for life to be good for a subject, thus making the unconscious ethically relevant. Glasgow Coma Scale The Glasgow Coma Scale ( GCS ) is a clinical scale used to reliably measure

2070-639: Is identical to the current scale except for the motor assessment. The original motor assessment included only five levels, combining "flexion" and "abnormal flexion". This was done because Jennett and Teasdale found that many people struggled in distinguishing these two states. In 1976, Teasdale updated the motor component of the Glasgow Coma Scale to differentiate flexion movements. This was because trained personnel could reliably distinguish flexion movements. Further research also demonstrated that normal and abnormal flexion have different clinical outcomes. As

2139-422: Is sustained through the use of intubation , ventilation , administration of intravenous fluids or blood and other supportive care as needed. Once a patient is stable and no longer in immediate danger, there may be a shift of priority from stabilizing the patient to maintaining the state of their physical wellbeing. Moving patients every 2–3 hours by turning them side to side is crucial to avoiding bed sores as

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2208-452: Is used in research to define patient groups. It is also used in clinical practice as shorthand for the full scale. The Glasgow Coma Scale was initially adopted by nursing staff in the Glasgow neurosurgical unit. Especially following a 1975 nursing publication, it was adopted by other medical centres. True widespread adoption of the GCS was attributed to two events in 1978. First, Tom Langfitt,

2277-432: Is used on rare occasions for TBIs i.e. when there is suspicion of an aneurysm, carotid sinus fistula, traumatic vascular occlusion, and vascular dissection. A CT can detect changes in density between the brain tissue and hemorrhages like subdural and intracerebral hemorrhages. MRIs are not the first choice in emergencies because of the long scanning times and because fractures cannot be detected as well as CT. MRIs are used for

2346-483: The University of Glasgow Medical School began work on what became the Glasgow Coma Scale. Based on their experiences, they aimed to make a scale satisfying several criteria. First, it needed to be simple, so that it could be performed without special training. Second, it needed to be reliable, so that doctors could be confident in the results of the scale. Third, the scale needed to provide important information for managing

2415-404: The cerebrum is composed of white matter and is composed of the axons of neuron . White matter is responsible for perception , relay of the sensory input via the thalamic pathway, and many other neurological functions, including complex thinking. The RAS, on the other hand, is a more primitive structure in the brainstem which includes the reticular formation (RF). The RAS has two tracts,

2484-445: The metaphysical and bioethical views on comas. It has been argued that unawareness should be just as ethically relevant and important as a state of awareness and that there should be metaphysical support of unawareness as a state. In the ethical discussions about disorders of consciousness (DOCs), two abilities are usually considered as central: experiencing well-being and having interest . Well-being can broadly be understood as

2553-408: The mitochondria and then move into the cytosol . The process is known as the urea cycle , which comprises several enzymes acting in sequence. It is greatly exacerbated by common zinc deficiency , which raises ammonia levels further. Normal blood ammonia levels in adults range from 20 to 50   μmol/L or less than 26 to 30   μmol/L. There is at present no clear scientific consensus on

2622-565: The age of 36 months (when the verbal performance of even a healthy child would be expected to be poor). Consequently, the Paediatric Glasgow Coma Scale was developed for assessing younger children. During the 1960s, assessment and management of head injuries became a topic of interest. The number of head injuries was rapidly increasing, in part because of increased use of motorised transport. Also, doctors recognised that after head trauma, many patients had poor recovery. This led to

2691-431: The airway. Imaging encompasses computed tomography (CAT or CT) scan of the brain, or MRI for example, and is performed to identify specific causes of the coma, such as hemorrhage in the brain or herniation of the brain structures. Special tests such as an EEG can also show a lot about the activity level of the cortex such as semantic processing, presence of seizures , and are important available tools not only for

2760-476: The ascending and descending tract. The ascending tract, or ascending reticular activating system (ARAS), is made up of a system of acetylcholine-producing neurons, and works to arouse and wake up the brain. Arousal of the brain begins from the RF, through the thalamus , and then finally to the cerebral cortex. Any impairment in ARAS functioning, a neuronal dysfunction, along the arousal pathway stated directly above, prevents

2829-564: The assessment of the cortical activity but also for predicting the likelihood of the patient's awakening. The autonomous responses such as the skin conductance response may also provide further insight on the patient's emotional processing. In the treatment of traumatic brain injury (TBI), there are 4 examination methods that have proved useful: skull x-ray, angiography, computed tomography (CT), and magnetic resonance imaging (MRI). The skull x-ray can detect linear fractures, impression fractures (expression fractures) and burst fractures. Angiography

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2898-505: The blood) are examples of a metabolic diffuse neuronal dysfunction. Hypoglycemia or hypercapnia initially cause mild agitation and confusion, but progress to obtundation , stupor, and finally, complete unconsciousness . In contrast, coma resulting from a severe traumatic brain injury or subarachnoid hemorrhage can be instantaneous. The mode of onset may therefore be indicative of the underlying cause. Structural and diffuse causes of coma are not isolated from one another, as one can lead to

2967-433: The body from being aware of its surroundings. Without the arousal and consciousness centers, the body cannot awaken, remaining in a comatose state. The severity and mode of onset of coma depends on the underlying cause. There are two main subdivisions of a coma: structural and diffuse neuronal. A structural cause, for example, is brought upon by a mechanical force that brings about cellular damage, such as physical pressure or

3036-409: The brain, like meningitis and encephalitis . Injury to either or both of the cerebral cortex or the reticular activating system (RAS) is sufficient to cause a person to enter coma. The cerebral cortex is the outer layer of neural tissue of the cerebrum of the brain . The cerebral cortex is composed of gray matter which consists of the nuclei of neurons , whereas the inner portion of

3105-442: The cause of the coma; the following table is a technical, medical guideline for common pupil findings and their possible interpretations: A coma can be classified as (1) supratentorial (above Tentorium cerebelli ), (2) infratentorial (below Tentorium cerebelli), (3) metabolic or (4) diffused. This classification is merely dependent on the position of the original damage that caused the coma, and does not correlate with severity or

3174-413: The cause, location, severity and extent of neurological damage. A deeper coma alone does not necessarily mean a slimmer chance of recovery; similarly, a milder coma does not indicate a higher chance of recovery. The most common cause of death for a person in a vegetative state is secondary infection such as pneumonia , which can occur in patients who lie still for extended periods. People may emerge from

3243-482: The coma, some progress to a vegetative state or a minimally conscious state , and others die. Some patients who have entered a vegetative state go on to regain a degree of awareness; and in some cases may remain in vegetative state for years or even decades (the longest recorded period is 42 years, the Aruna Shanbaug case ). Predicted chances of recovery will differ depending on which techniques were used to measure

3312-412: The excretion of waste nitrogen. Phenylbutyrate , which is the product of phenylacetate, conjugates with glutamine to form phenylacetylglutamine , which is excreted by the kidneys. Similarly, sodium benzoate reduces ammonia content in the blood by conjugating with glycine to form hippuric acid , which is rapidly excreted by the kidneys. A preparation containing sodium phenylacetate and sodium benzoate

3381-465: The external environment, including other people. According to Hawkins, "1. A life is good if the subject is able to value, or more basically if the subject is able to care. Importantly, Hawkins stresses that caring has no need for cognitive commitment, i.e. for high-level cognitive activities: it requires being able to distinguish something, track it for a while, recognize it over time, and have certain emotional dispositions vis-à-vis something. 2. A life

3450-438: The family members of the affected patients, as well as the primary care givers taking care of the patients. Research has shown that the severity of injury causing coma was found to have no significant impact compared to how much time has passed since the injury occurred. Common reactions, such as desperation, anger, frustration, and denial are possible. The focus of the patient care should be on creating an amicable relationship with

3519-406: The family members or dependents of a comatose patient as well as creating a rapport with the medical staff. Although there is heavy importance of a primary care taker, secondary care takers can play a supporting role to temporarily relieve the primary care taker's burden of tasks. Comas can last from several days to, in particularly extreme cases, years. Some patients eventually gradually come out of

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3588-460: The functioning of the ARAS and lead to a coma. Given that drug poisoning is the cause for a large portion of patients in a coma, hospitals first test all comatose patients by observing pupil size and eye movement, through the vestibular-ocular reflex . (See Diagnosis below.) The second most common cause of coma, which makes up about 25% of cases, is lack of oxygen, generally resulting from cardiac arrest . The Central Nervous System (CNS) requires

3657-403: The idea of an unconscious well-being. As such, the ability of having interests is crucial for describing two abilities which those with comas are deficient in. Having an interest in a certain domain can be understood as having a stake in something that can affect what makes our life good in that domain. An interest is what directly and immediately improves life from a certain point of view or within

3726-428: The imaging of soft tissues and lesions in the posterior fossa which cannot be found with the use of CT. Assessment of the brainstem and cortical function through special reflex tests such as the oculocephalic reflex test (doll's eyes test), oculovestibular reflex test (cold caloric test), corneal reflex , and the gag reflex . Reflexes are a good indicator of what cranial nerves are still intact and functioning and

3795-590: The man with a traumatic brain injury. His injuries left him in a minimally conscious state, a condition akin to a coma but characterized by occasional, but brief, evidence of environmental and self-awareness that coma patients lack. Research by Eelco Wijdicks on the depiction of comas in movies was published in Neurology in May 2006. Wijdicks studied 30 films (made between 1970 and 2004) that portrayed actors in prolonged comas, and he concluded that only two films accurately depicted

3864-486: The other in some situations. For instance, coma induced by a diffuse metabolic process, such as hypoglycemia, can result in a structural coma if it is not resolved. Another example is if cerebral edema, a diffuse dysfunction, leads to ischemia of the brainstem, a structural issue, due to the blockage of the circulation in the brain. Although diagnosis of coma is simple, investigating the underlying cause of onset can be rather challenging. As such, after gaining stabilization of

3933-447: The patient is under closer observation, and when shifts between levels are more frequent. Treatment for people in a coma will depend on the severity and cause of the comatose state. Upon admittance to an emergency department, coma patients will usually be placed in an Intensive Care Unit (ICU) immediately, where maintenance of the patient's respiration and circulation become a first priority. Stability of their respiration and circulation

4002-440: The patient's airways, breathing and circulation (the basic ABCs ) various diagnostic tests, such as physical examinations and imaging tools ( CT scan , MRI , etc.) are employed to access the underlying cause of the coma. When an unconscious person enters a hospital, the hospital utilizes a series of diagnostic steps to identify the cause of unconsciousness . According to Young, the following steps should be taken when dealing with

4071-441: The patient's severity of neurological damage. Predictions of recovery are based on statistical rates, expressed as the level of chance the person has of recovering. Time is the best general predictor of a chance of recovery. For example, after four months of coma caused by brain damage , the chance of partial recovery is less than 15%, and the chance of full recovery is very low. The outcome for coma and vegetative state depends on

4140-399: The positive effect related to what makes life good (according to specific standards) for the individual in question. The only condition for well-being broadly considered is the ability to experience its 'positiveness'. That said, because experiencing positiveness is a basic emotional process with phylogenetic roots, it is likely to occur at a completely unaware level and, therefore, introduces

4209-429: The prognosis. The severity of coma impairment however 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. The Rancho Los Amigos Scale is a complex scale that has eight separate levels, and is often used in the first few weeks or months of coma while

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4278-471: The scale's poor inter-rater reliability and lack of prognostic utility. Although there is no agreed-upon alternative, newer scores such as the simplified motor scale and FOUR score have also been developed as improvements to the GCS. Although the inter-rater reliability of these newer scores has been slightly higher than that of the GCS, they have not yet gained consensus as replacements. Hyperammonemia Hyperammonemia , or high ammonia levels ,

4347-421: The senses) and apoplexy (into which carus could turn and which he localized in the white matter ) are mentioned. The term carus is also derived from Greek, where it can be found in the roots of several words meaning soporific or sleepy. It can still be found in the root of the term 'carotid'. Thomas Sydenham (1624–89) mentioned the term 'coma' in several cases of fever (Sydenham, 1685). General symptoms of

4416-517: The state of a coma patient and the agony of waiting for a patient to awaken: Reversal of Fortune (1990) and The Dreamlife of Angels (1998). The remaining 28 were criticized for portraying miraculous awakenings with no lasting side effects, unrealistic depictions of treatments and equipment required, and comatose patients remaining muscular and tanned. A person in a coma is said to be in an unconscious state. Perspectives on personhood , identity and consciousness come into play when discussing

4485-537: The table below. The Glasgow Coma Scale is reported as the combined score (which ranges from 3 to 15) and the score of each test (E for eye, V for Verbal, and M for Motor). For each test, the value should be based on the best response that the person being examined can provide. For example, if a person obeys commands only on their right side, they get a 6 for motor. The scale also accounts for situations that prevent appropriate testing (Not Testable). When specific tests cannot be performed, they must be reported as "NT" and

4554-407: The total score is not reported. The results are reported as the Glasgow Coma Score (the total points from the three tests) and the individual components. As an example, a person's score might be: GCS 12, E3 V4 M5. Alternatively, if a patient was intubated, their score could be GCS E2 V NT M3. Children below the age of two struggle with the tests necessary for assessment of the Glasgow Coma Scale. As

4623-441: The trachea to the lungs). This trapping of matter in their lower respiratory tract can ultimately lead to infection, resulting in aspiration pneumonia . Coma patients may also deal with restlessness or seizures. As such, soft cloth restraints may be used to prevent them from pulling on tubes or dressings and side rails on the bed should be kept up to prevent patients from falling. Coma has a wide variety of emotional reactions from

4692-609: The upper limits of ammonia levels for different age groups. In any case, hyperammonemia is generally defined as ammonia levels greater than 50   μmol/L in adults and greater than 100   μmol/L in newborns. These values should be considered as decision limits and the normal reference ranges of individual laboratories should be used for clinical interpretation. When ammonia levels rise greater than 200   μmol/L, serious symptoms, including seizures , encephalopathy , coma , and even death, can occur. Hyperammonemia with blood ammonia levels greater than 400 to 500   μmol/L

4761-446: The verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached (e.g. "E1c", where "c" = closed, or "V1t" where t = tube). Often the 1 is left out, so the scale reads Ec or Vt. A composite might be "GCS 5tc". This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for "abnormal flexion". The GCS has limited applicability to children, especially below

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