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| | __NOTOC__ |
| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
| | {{Coma}} |
| | {{CMG}} '''Associate Editor(s)-in-Chief:''' [[User:Raviteja Reddy Guddeti|Raviteja Guddeti, M.B.B.S.]] [mailto:ravitheja.g@gmail.com] |
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| {{Infobox_Disease |
| | ==[[Coma overview|Overview]]== |
| | Name = Coma
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| | ICD10 = {{ICD10|R|40|2|r|40}}
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| | ICD9 = {{ICD9|780.01}}
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| {{SI}}
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| {{CMG}}
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| {{EH}}
| | ==[[Coma historical perspective|Historical Perspective]]== |
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| ==Overview== | | ==[[Coma pathophysiology|Pathophysiology]]== |
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| In [[medicine]], a '''coma''' (from the [[Greek language|Greek]] {{polytonic|κῶμα}} ''koma'', meaning deep sleep) is a profound state of [[unconsciousness]]. A comatose patient cannot be awakened, fails to respond normally to pain or light, does not have sleep-wake cycles, and does not take voluntary actions. Coma may result from a variety of conditions, including [[intoxication]], [[metabolism|metabolic]] abnormalities, central nervous system diseases, acute neurologic injuries such as [[stroke]], and [[Hypoxia (medical)|hypoxia]]. It may also be deliberately [[induced coma|induced]] 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. A coma may also result from immense [[head trauma]] caused by something like a car accident or a series of very severe [[concussion]]s. The underlying cause of the coma is bilateral damage to the [[Reticular formation]] of the [[midbrain]], which is important in regulating sleep <ref> The Human Brain: an introduction to its functional anatomy 5th ed by J Nolte chpt 11 pp262-290 </ref>.
| | ==[[Coma causes|Causes]]== |
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| == Differential Diagnosis of Causes of Coma== | | ==[[Coma differential diagnosis|Differentiating Coma from other Diseases]]== |
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| ==== The Most Common Causes of Coma==== | | ==[[Coma epidemiology and demographics|Epidemiology and Demographics]]== |
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| * Cerebral masses
| | ==[[Coma risk factors|Risk Factors]]== |
| * [[Encephalitis]]
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| * [[Endocrine encephalopathies]]
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| * [[Heatstroke]]
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| * [[Intoxication]]
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| * [[Psychoses]]
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| * [[Ddx:Intracranial Bleeding|Subarachnoid hemorrhage]]
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| * [[Ddx:Syncope|Syncopes]]
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| ===The Complete List of Causes of Coma=== | | ==[[Coma natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| * Acute hemorrhagic leukoencephalitis
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| * Addisonian crisis
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| * '''AEIOU-TIPS'''
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| *:* [[Alcohol]]
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| *:* [[Encephalitis]]
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| *:* [[Insulin]]
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| *:* [[Opiates]]
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| *:* [[Uremia]]
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| *:* [[Trauma]]
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| *:* Infection
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| *:* Psychiatric
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| *:* [[Ddx:Syncope|Syncope]]
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| * Apallic Syndrome
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| * [[Biguanides]]
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| * Bilateral [[subdural hematoma]]
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| * Blood pressure disorders
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| * [[Brain abscess]] with [[edema]]
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| * Brain hemorrhage
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| * Brain [[tumor]]
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| * [[Carcinomatosis]] [[meningitis]]
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| * [[Ddx:Cardiac Dysrhythmias|Cardiac dysrhythmias]]
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| * [[Catatonia]]
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| * Cerebral infarction with [[edema]]
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| * [[Cerebrovascular disease]]
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| * [[Concussion]]
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| * [[Congestive Heart Failure]]
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| * Consciousness shift
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| * [[Creutzfeldt-Jakob Disease]]
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| * [[Diabetes Insipidus]]
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| * [[Diabetic Acidosis]]
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| * Disseminated encephalomyelitis
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| * Drug withdrawal
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| * Drugs
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| * [[Eclampsia]]
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| * [[Endocarditis]]
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| * [[Epidural hematoma]]
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| * [[Focal seizures]]
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| * [[Hepatic coma]]
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| * [[Herpes]] [[encephalitis]]
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| * [[Hydrocephalus]]
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| * [[Ddx:Hypercalcemia|Hypercalcemia]]
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| * Hypercarbie
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| * [[Ddx:Hyperkalemia|Hyperkalemia]]
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| * [[Hypermagnesemia]]
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| * [[Ddx:Hypernatremia|Hypernatremia]]
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| * [[Hyperosmolality]]
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| * [[Hyperphosphatemia]]
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| * [[Hypertensive encephalopathy]]
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| * [[Ddx:Hyperthermia|Hyperthermia]]
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| * [[Ddx:Hypocalcemia|Hypocalcemia]]
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| * [[Ddx:Hypoglycemia|Hypoglycemia]]
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| * [[Ddx:Hypokalemia|Hypokalemia]]
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| * [[Hypomagnesemia]]
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| * [[Ddx:Hyponatremia|Hyponatremia]]
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| * [[Hypoosmolality]]
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| * [[Hypophosphatemia]]
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| * [[Ddx:Hypothermia|Hypothermia]]
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| * Hypothyroid crisis
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| * [[Hypoxia]]
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| * Hysterical coma
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| * [[Intracerebral hemorrhage]]
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| * Locked-In Syndrome
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| * [[Malaria]]
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| * [[Meningitis]]
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| * [[Ddx:Headache|Migraine]]
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| * Narrowed [[consciousness]]
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| * [[Pheochromocytoma]] crisis
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| * [[Pituitary insufficiency]]
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| * [[Pneumonia]]
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| * [[Porphyria]]
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| * Postictal state
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| * Postoperative
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| * Postpartum
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| * Profound nutritional deficiency
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| * [[Progressive multifocal leukoencephalopathy]]
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| * Pulmonary causes
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| * [[Reye's Syndrome]]
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| * [[Rheumatic Fever]]
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| * [[Septicemia]]
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| * Severe [[drug overdose]]
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| * [[Subdural hematoma]]
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| * [[Thiamine deficiency]]
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| * [[Thrombotic Thrombocytopenic Purpura]]
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| * Thyrotoxic crisis
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| * [[Tumor]] with [[edema]]
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| * [[Typhoid Fever]]
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| * [[Wernicke's Encephalopathy]]
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| ==Severity== | | ==Diagnosis== |
| | [[Coma history and symptoms|History and Symptoms]] | [[Coma physical examination|Physical Examination]] | [[Coma laboratory findings|Laboratory Findings]] | [[Coma CT|CT]] | [[Coma MRI|MRI]] | [[Coma other imaging findings|Other Imaging Findings]] | [[Coma other diagnostic studies|Other Diagnostic Studies]] |
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| 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.
| | ==Treatment== |
| | [[Coma medical therapy|Medical Therapy]] | [[Coma surgery|Surgery]] | [[Coma primary prevention|Primary Prevention]] | [[Coma secondary prevention|Secondary Prevention]] | [[Coma cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Coma future or investigational therapies|Future or Investigational Therapies]] |
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| 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.<ref>[http://news.bbc.co.uk/2/hi/europe/6715313.stm BBC NEWS | Europe | Pole wakes up from 19-year coma<!-- Bot generated title -->]</ref>
| | == Case Studies == |
| | [[Coma case study one|Case #1]] |
| | ==Related Chapters== |
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| Two scales of measurement often used in [[Traumatic Brain Injury|TBI]] diagnosis to determine the level of coma are the [[Glasgow Coma Scale]] (GCS) and the [[Rancho Los Amigos Scale|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 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.
| | * [[Persistent vegetative state]] |
| | | * [[Brain death]] |
| ==Outcome==
| | * [[Process Oriented Coma Work]] |
| | | ==External Links== |
| Outcomes range from recovery to [[death]]. Comas generally last a few days to a few weeks. They rarely last more than 2 to 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 [[Persistent vegetative state|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).
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| <REF>
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| According to the Guinness Book of Records, the longest period spent in coma was by Elaine Esposito. She did not wake up after being [[Anesthesia|anaesthetized]] for an [[appendectomy]] on August 6, 1941, at age 6. She died on November 25 1978 at age 43 years 357 days, having been in a coma for 37 years 111 days.
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| </REF>
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| 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.
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| 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.
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| 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]] 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]], the chance of partial recovery is less than 15%, and the chance of full recovery is very low. <ref>[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15118882&query_hl=5 Clinical predictors and neuropsychological outcome...[Acta Neurochir (Wien). 2004] - PubMed Result<!-- Bot generated title -->]</ref><ref>[http://www.braininjury.com/coma.html brain injury .com | Coma traumatic brain injury - Brain Injury Coma<!-- Bot generated title -->]</ref>
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| 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.
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| Occasionally people come out of 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. <ref>[http://www.smh.com.au/articles/2003/07/11/1057783356390.html Mother stunned by coma victim's unexpected words - smh.com.au<!-- Bot generated title -->]</ref>
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| 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 electrical stimulation (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]] (MCS), a condition akin to a coma but characterized by occasional, but brief, evidence of environmental and self-awareness that coma patients lack. <ref>{{cite news |title=Electrodes stir man from six-year coma-like state |url=http://www.cosmosmagazine.com/node/1513 |work=Cosmos Magazine |date=02 August 2007}}</ref>
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| ==See also==
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| * [[Persistent vegetative state]] (vegetative coma), deep coma without detectable awareness | |
| * [[Brain death]] (irreversible coma), irreversible end of all brain activity | |
| * [[Process Oriented Coma Work]], for an approach to working with residual consciousness in comatose patients | |
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| ==References== | |
| {{Reflist|2}}
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| ==Additional Resources==
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| * BIAUSA (Brain Injury Association of America), [http://www.biausa.org/Pages/types_of_brain_injury.html#diffuse Types of Brain Injury].
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| * NINDS (National Institute of Neurological Diseases and Stroke), [http://www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm public domain information on TBI] | | * NINDS (National Institute of Neurological Diseases and Stroke), [http://www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm public domain information on TBI] |
| * NINDS (National Institute of Neurological Diseases and Stroke), [http://www.ninds.nih.gov/health_and_medical/disorders/coma_doc.htm public domain information on coma] | | * NINDS (National Institute of Neurological Diseases and Stroke), [http://www.ninds.nih.gov/health_and_medical/disorders/coma_doc.htm public domain information on coma] |
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| ==External links==
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| * [http://www.newsmonster.co.uk/waking-coma-victims-with-a-sleeping-pill.html Waking coma patients with a sleeping pill]
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| * [http://www.biaq.com.au/factsheets.htm Brain Injury Fact Sheets - Information on coma, and many other effects of brain injury.]
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| * [http://www.neuroskills.com/ TBI Resource Guide] Central source of information, services and products relating to brain injury, brain injury recovery, and post-acute rehabilitation.
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| {{Cognition, perception, emotional state and behaviour symptoms and signs}} | | {{Cognition, perception, emotional state and behaviour symptoms and signs}} |
| {{Intensive care medicine}} | | {{Intensive care medicine}} |
| {{SIB}}
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| [[Category:Neurology]]
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| [[Category:Intensive care medicine]]
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| [[Category:Emergency medicine]]
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| [[Category:Central nervous system]]
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| [[ast:Coma (médicu)]] | | [[ast:Coma (médicu)]] |
| [[bs:Koma]] | | [[bs:Koma]] |
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| {{WH}} | | {{WH}} |
| {{WS}} | | {{WS}} |
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| | [[Category:Neurology]] |
| | [[Category:Intensive care medicine]] |
| | [[Category:Emergency medicine]] |
| | [[Category:Central nervous system]] |