In medicine Medicine is the science and art of healing humans. It includes a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness. Before scientific medicine, healing arts were practiced along with alchemical and ritual practices that developed out of religious and cultural traditions. The term &, a coma (from the Greek Greek , an independent branch of the Indo-European family of languages, is the language of the Greeks. Native to the southern Balkans, it has the longest documented history of any Indo-European language, spanning 34 centuries of written records. In its ancient form, it is the language of classical ancient Greek literature and the New Testament of κῶμα koma, meaning deep sleep) is a profound state of unconsciousness Unconsciousness, more appropriately referred to as loss of consciousness or lack of consciousness, is a dramatic alteration of mental state that involves complete or near-complete lack of responsiveness to people and other environmental stimuli. Being in a comatose state or coma is an illustration of unconsciousness. Fainting due to a drop in. A person in a coma cannot be awakened, fails to respond normally to pain, light or sound, does not have sleep-wake cycles A circadian rhythm is a roughly 24-hour cycle in the biochemical, physiological, or behavioural processes of living entities, including plants, animals, fungi and cyanobacteria . The term "circadian" comes from the Latin circa, "around", and diem or dies, "day", meaning literally "approximately one day". The, and does not take voluntary actions. A person in a state of coma can be described as comatose.

Coma may result from a variety of conditions, including intoxication, metabolic Metabolism is the set of chemical reactions that happen in living organisms to maintain life. These processes allow organisms to grow and reproduce, maintain their structures, and respond to their environments. Metabolism is usually divided into two categories. Catabolism breaks down organic matter, for example to harvest energy in cellular abnormalities, central nervous system diseases, acute neurologic injuries such as stroke A stroke (sometimes called a cerebrovascular accident ) is the rapidly developing loss of brain function(s) due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood). As a result, the affected area of the brain is, and hypoxia Hypoxia is a pathological condition in which the body as a whole or a region of the body (tissue hypoxia) is deprived of adequate oxygen supply. Variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise. A mismatch between oxygen supply and its demand at the cellular level. A coma may also result from head trauma Head injury refers to trauma to the head. This may or may not include injury to the brain. However, the terms traumatic brain injury and head injury are often used interchangeably in the medical literature caused by mechanisms such as falls or car accidents A traffic collision is when a road vehicle collides with another vehicle, pedestrian, animal, road debris, or other geographical or architectural obstacle. Traffic collisions can result in injury, property damage, and death. It may also be deliberately induced A barbiturate-induced coma, or barb coma, is a temporary coma brought on by a controlled dose of a barbiturate drug, usually pentobarbital or thiopental. Barbiturate comas are used to protect the brain during major neurosurgery, and as a last line of treatment in certain cases of status epilepticus that have not responded to other treatments by pharmaceutical agents in order to preserve higher brain function following another form of brain trauma, or to save the patient from extreme pain during healing of injuries or diseases. The underlying cause of coma is bilateral damage to the reticular formation The reticular formation is a part of the brain that is involved in actions such as awaking/sleeping cycle, and filtering incoming stimuli to discriminate irrelevant background stimuli. It is essential for governing some of the basic functions of higher organisms, and is one of the phylogenetically oldest portions of the brain of the hindbrain The rhombencephalon is a developmental categorization of portions of the central nervous system in vertebrates, which is important in regulating sleep.^[1]

If the cause of coma is not clear, various investigations (blood tests A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick, medical imaging Medical imaging is the technique and process used to create images of the human body for clinical purposes (medical procedures seeking to reveal, diagnose or examine disease) or medical science (including the study of normal anatomy and physiology). Although imaging of removed organs and tissues can be performed for medical reasons, such) may be performed to establish the cause and identify reversible causes. Coma usually necessitates admission to a hospital A hospital, in the modern sense of the word, is an institution for health care providing patient treatment by specialized staff and equipment, and often, but not always providing for longer-term patient stays. Its historical meaning, until relatively recent times, was "a place of hospitality", for example the Chelsea Royal Hospital, and often the intensive care unit An intensive care unit , critical care unit (CCU), intensive therapy unit or intensive treatment unit (ITU) is a specialized department used in many countries' hospitals that provides intensive care medicine. Many hospitals also have designated intensive care areas for certain specialities of medicine, as dictated by the needs and available.

Signs and symptoms

The severity and mode of onset of coma depends on the underlying cause. For instance, deepening hypoglycemia Hypoglycemia or hypoglycæmia is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means "under-sweet blood" . It can produce a variety of symptoms and effects but the principal problems arise from an inadequate supply of glucose to the brain, resulting in impairment of function ( (low blood sugar) or hypercapnia Hypercapnia or hypercapnea , also known as hypercarbia, is a condition where there is too much carbon dioxide (CO2) in the blood. Carbon dioxide is a gaseous product of the body's metabolism and is normally expelled through the lungs (increased carbon dioxide Carbon dioxide is a chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom. It is a gas at standard temperature and pressure and exists in Earth's atmosphere in this state. CO2 is a trace gas comprising 0.039% of the atmosphere levels in the blood) initially cause mild agitation and confusion, then progress to obtundation Obtundation refers to less than full mental capacity in a medical patient, typically as a result of a medical condition or trauma. The root word, obtund, means "dulled or less sharp", stupor and finally complete unconsciousness. In contrast, coma resulting from a severe traumatic brain injury Traumatic brain injury occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g. occurring in a specific location or over a widespread area). Head injury usually refers to TBI, but is a broader category because it can involve damage or subarachnoid hemorrhage A subarachnoid hemorrhage (SAH, pronounced /ˌsʌbəˈræknɔɪd ˈhɛmrɪdʒ/, or subarachnoid haemorrhage in British English) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. This may occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head can be instantaneous. The mode of onset may therefore be indicative of the underlying cause.

In the initial assessment of coma, it is common to gauge the level of consciousness An altered level of consciousness is an measure of arousal other than normal. Level of consciousness is a measurement of a person's arousability and responsiveness to stimuli from the environment. A mildly depressed level of consciousness may be classed as lethargy; someone in this state can be aroused with little difficulty. People who are by spontaneously exhibited actions, response to vocal stimuli ("Can you hear me?"), and painful stimuli; this is known as the AVPU (alert, vocal stimuli, painful stimuli, unconscious) scale. More elaborate scales, such as the Glasgow coma scale Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 and either 14 (original scale) or 15 (the more (see below), quantify individual reactions such as eye opening, movement and verbal response on a scale.

In those with deep unconsciousness, there is a risk of asphyxiation Asphyxia is a condition of severely deficient supply of oxygen to the body that arises from being unable to breathe normally. An example of asphyxia is choking. Asphyxia causes generalized hypoxia, which primarily affects the tissues and organs 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 In nearly all circumstances airway management is the highest priority for clinical care. This is because if there is no airway, there can be no breathing, hence no oxygenation of blood and therefore circulation will soon cease. Getting oxygen to the lungs is the first step in almost all clinical treatments. The ‘A’ is for ‘airway’ in the â€"). If the risk of asphyxiation is deemed to be high, doctors may use various devices (such as an oropharyngeal airway Oropharyngeal airways come in a variety of sizes, from infant to adult, and are used mostly in pre-hospital emergency care. This piece of equipment is utilized by certified first responders, emergency medical technicians, and paramedics when intubation is either not available or not advisable, nasopharyngeal airway In medicine, a nasopharyngeal airway, also known as an NPA or a nasal trumpet because of its flared end, a type of airway adjunct, is a tube that is designed to be inserted into the nasal passageway to secure an open airway. When a patient becomes unconscious, the muscles in the jaw commonly relax and can allow the tongue to slide back and or endotracheal tube An endotracheal tube is used in general anaesthesia, intensive care and emergency medicine for airway management, mechanical ventilation and as an alternative route for many drugs if an IV line cannot be established. The tube is inserted into a patient's trachea in order to ensure that the airway is not closed off and that air is able to reach the) to safeguard the airway.

Diagnosis

Once a person in a coma is stable, investigations are performed to assess the underlying cause. These may be simple; a computed tomography Computed tomography is a medical imaging method employing tomography created by computer processing. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation scan of the brain, for example, is performed to identify specific causes of the coma, such as hemorrhage Bleeding, technically known as hemorrhaging or haemorrhaging is the loss of blood or blood escape from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either through a natural opening such as the vagina, mouth, nose, ear or anus, or through a break in the skin. The complete.

A diagnosis will direct the appropriate therapy, however it does not reduce the need for generic supportive care, such as that offered on intensive care. Sometimes, the diagnosis allows the withdrawal of care, if the cause of coma is untreatable and the brain damage is irreversible.

Classification

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.

Two scales of measurement often used in Traumatic Brain Injury Traumatic brain injury occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g. occurring in a specific location or over a widespread area). Head injury usually refers to TBI, but is a broader category because it can involve damage (TBI) diagnosis to determine the level of coma are the Glasgow Coma Scale Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 and either 14 (original scale) or 15 (the more (GCS) and the Ranchos Los Amigos Scale The Rancho Los Amigos Scale is a medical scale intended to assess the level of recovery of brain injury patients and those recovering from coma. It is named after the Rancho Los Amigos National Rehabilitation Center (RLAS). The GCS is a simple 3 to 15-point scale (3 being the worst and 15 being that of a normal 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.

Prognosis

Outcomes range from recovery to death. Comas generally last a few days to a few weeks. They rarely last more than 5 weeks but some have lasted as long as several years. After this time, some patients gradually come out of the coma, some progress to a vegetative state A persistent vegetative state is a condition of patients with severe brain damage who were in a coma, but progressed to a state of wakefulness without detectable awareness. It is a diagnosis of some uncertainty in that it deals with a syndrome. After four weeks in a Vegetative State , the patient is classified as in a Persistent Vegetative State, and others die. Some patients who have entered a vegetative state go on to regain a degree of awareness. Others remain in a vegetative state for years or even decades (the longest recorded period being 37 years).^[2]

The outcome for coma and vegetative state depends on the cause, location, severity and extent of neurological damage. A deeper coma alone does not necessarily mean a slimmer chance of recovery, because some people in deep coma recover well while others in a so-called milder coma sometimes fail to improve.

People may emerge from a coma with a combination of physical, intellectual and psychological difficulties that need special attention. Recovery usually occurs gradually—patients acquire more and more ability to respond. Some patients never progress beyond very basic responses, but many recover full awareness. Regaining consciousness is not instant: in the first days, patients are only awake for a few minutes, and duration of time awake gradually increases. This is unlike the situation in many movies where people who awake from comas are instantly able to continue their normal lives. In reality, the coma patient awakes sometimes in a profound state of confusion, not knowing how they got there and sometimes suffering from dysarthria Dysarthria is a motor speech disorder resulting from neurological injury, characterized by poor articulation . Any of the speech subsystems (respiration, phonation, resonance, prosody, and articulation) can be affected, the inability to articulate any speech, and with many other disabilities.

Predicted chances of recovery are variable owing to different techniques used to measure the extent of neurological damage. All the predictions are based on statistical Statistics is the formal science of making effective use of numerical data relating to groups of individuals or experiments. It deals with all aspects of this, including not only the collection, analysis and interpretation of such data, but also the planning of the collection of data, in terms of the design of surveys and experiments rates with some level of chance for recovery present: a person with a low chance of recovery may still awaken. Time is the best general predictor of a chance of recovery: after 4 months of coma caused by brain damage 'Brain damage' is a term no longer used today and has been replaced in recent decades by 'brain injury' ; meaning the destruction or degeneration of brain cells, often with an implication that the loss is significant in terms of functioning or conscious experience. It is a common and very broad in scope, such that in medicine a vast range of, the chance of partial recovery is less than 15%, and the chance of full recovery is very low.^[3][4]

The most common cause of death for a person in a vegetative state is secondary infection An infection is the detrimental colonization of a host organism by a foreign species. In an infection, the infecting organism seeks to utilize the host's resources to multiply, usually at the expense of the host. The infecting organism, or pathogen, interferes with the normal functioning of the host and can lead to chronic wounds, gangrene, loss such as pneumonia Pneumonia is an inflammatory condition of the lung. It is often characterized as including inflammation of the parenchyma of the lung and abnormal alveolar filling with fluid (consolidation and exudation) which can occur in patients who lie still for extended periods.

Occasionally people come out of coma after long periods of time. After 19 years in a minimally conscious state A minimally conscious state is a condition distinct from coma or the vegetative state, in which a patient exhibits deliberate, or cognitively mediated, behavior often enough, or consistently enough, for clinicians to be able to distinguish it from entirely unconscious, reflexive responses, Terry Wallis Terry Wallis is an American man living in the Ozark Mountains of Arkansas who on June 11, 2003 regained awareness after spending almost 20 years in a minimally conscious state spontaneously began speaking and regained awareness of his surroundings.^[5] Similarly, Polish Poland /ˈpəʊlənd/ (Polish: Polska), officially the Republic of Poland (Rzeczpospolita Polska), is a country in Central Europe bordered by Germany to the west; the Czech Republic and Slovakia to the south; Ukraine, Belarus and Lithuania to the east; and the Baltic Sea and Kaliningrad Oblast, a Russian exclave, to the north. The total area of railroad worker Jan Grzebski Jan Grzebski was a Polish railroad worker who fell into a coma in 1988 and woke up in 2007. Although widely reported as a delayed effect of being hit in the head by a train's hinged car side, the coma was actually the result of a 5-centimeter brain tumor. Over time, Grzebski's aging caused the tumor to shrink enough to relieve pressure on his woke up from a 19-year coma in 2007.

A brain-damaged man, 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 Deep brain stimulation is a surgical treatment involving the implantation of a medical device called a brain pacemaker, which sends electrical impulses to specific parts of the brain. DBS in select brain regions has provided remarkable therapeutic benefits for otherwise treatment-resistant movement and affective disorders such as chronic pain, (DBS) successfully roused communication, complex movement and eating ability in the 38-year-old American man who suffered a traumatic brain injury. His injuries left him in a minimally conscious state A minimally conscious state is a condition distinct from coma or the vegetative state, in which a patient exhibits deliberate, or cognitively mediated, behavior often enough, or consistently enough, for clinicians to be able to distinguish it from entirely unconscious, reflexive responses (MCS), a condition akin to a coma but characterized by occasional, but brief, evidence of environmental and self-awareness that coma patients lack.^[6]

Society and culture

Research by Dr. Eelco Wijdicks on the depiction of comas in movies was published in Neurology in May 2006. Dr. Wijdicks studied 30 films (made between 1970 and 2004) that portrayed actors in prolonged comas, and he concluded that only two films accurately depicted the state of a coma victim and the agony of waiting for a patient to awaken: Reversal of Fortune Reversal of Fortune is a 1990 film adapted from the 1985 book Reversal of Fortune: Inside the von Bülow Case, written by law professor Alan Dershowitz. It recounts the true story of the unexplained coma of socialite Sunny von Bülow, the subsequent attempted murder trial, and the eventual acquittal of her husband, Claus von Bülow, who had (1990) and The Dreamlife of Angels (1998). The remaining 28 were criticised for portraying miraculous awakenings with no lasting side effects, unrealistic depictions of treatments and equipment required, and comatose patients remaining muscular and tanned^[7].

In the 2005 novel The Coma by Alex Garland, a man assaulted in the London Underground tries to put his life back into order from his comatose state. Extraordinary Means, a 1987 novel by Donna Levin, is a literary fantasy in which a comatose woman is able to overhear her family dispute over whether to end life support. Coma Coma is Robin Cook's first published novel, written in 1977. The book was a New York Times best seller and was also voted as the number one thriller of the year by the New York Times, published in 1977 by Robin Cook, is a medical thriller in which a med student unravels a plot to purposely induce comas in patients in order to harvest their organs.

In the film Just Like Heaven, a doctor who was seriously injured in a car accident falls into a coma that lasts for three months. Meanwhile, the woman's spirit goes back to her apartment, to find that it has been rented out to someone else. Together, the spirit and the man occupying her house find her body and bring her back to life.

In Rocky II, Adrian, Rocky's wife falls into a coma after giving birth, she wakes up and survives.

In the novel, Girlfriend in a Coma by Douglas Coupland Douglas Coupland (born December 30, 1961) is a Canadian novelist. His fiction is complemented by recognized works in design and visual art arising from his early formal training. His first novel, the 1991 international bestseller Generation X: Tales for an Accelerated Culture, popularized terms such as McJob and Generation X. He has published, one of their main characters, Karen, falls into a coma after consuming alcohol and valium.

In the novel The Opal Deception by Eoin Colfer, antagonist Opal Koboi fakes a coma inside an asylum to avoid incarceration.

In the Stephen King novel The Dead Zone, Johnny Smith falls into a coma after a car accident, waking five years later with minor brain damage and psychic powers.

In the film Teenage Mutant Ninja Turtles, Raphael falls into a coma after being beaten by the Foot. He later recovers after a few days.

In the film Miss March a man wakes up from a four year coma, to find out that his high school sweetheart became a playboy bunny.

In the film 28 Days Later, the lead character Jim wakes up from a 28 day coma, only to find that the world has been taken over by rage infected zombies.

British television series "Life On Mars" is based around the adventures of Sam Tyler. After being hit by a car he wakes up to find himself in 1973. Throughout the two series it is unclear if Sam is in a coma, gone mad, or has traveled back in time. At the conclusion of the final series, we discover Sam was indeed in a coma, prolonged by a tumor, and all the events that occurred were merely created by Sam's mind.

On the TV show Degrassi: The Next Generation, Terri McGreggor is put into a coma after her boyfriend pushes her down, resulting in her head hitting a cinder block. She stayed in the hospital for awhile and was later transferred to a private school.

From the art pop band, Gorillaz, lead singer Stuart "2D" Tusspot falls into a one-year coma after being hit in the head by a car.

See also

• Brain death (irreversible coma), irreversible end of all brain activity

• Coma scale, a system to assess the severity of coma

• Level of consciousness

• Locked-in syndrome

• Persistent vegetative state (vegetative coma), deep coma without detectable awareness

• Process Oriented Coma Work, for an approach to working with residual consciousness in comatose patients

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