Coma.

Coma is a state of unarousable unconsciousness due to dysfunction of the brain's ascending reticular activating system (ARAS), which is responsible for arousal and the maintenance of wakefulness. Anatomically and physiologically the ARAS has a redundancy of pathways and neurotransmitters; this may explain why coma is usually transient (seldom lasting more than 3 weeks). Emergence from coma is succeeded by outcomes ranging from the vegetative state to complete recovery, depending on the severity of damage to the cerebral cortex, the thalamus, and their integrated function. The clinical and laboratory assessments of the comatose patient are reviewed here, along with an analysis of how various conditions (structural brain lesions, metabolic and toxic disorders, trauma, infections, seizures, hypothermia, and hyperthermia) produce coma. Management issues include the determination of the cause and reversibility (prognosis) of neurological impairment, support of the patient, definitive treatment when possible, and the ethical considerations for those situations where marked disability is predicted with certainty.