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Skin signs of coma

Authors: Claire Jordan Wiggins, Riyad N.H. Seervai, Medical Students, Baylor College of Medicine, Houston, Texas, USA. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. June 2020.


Skin signs of coma — codes and concepts
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What is coma?

Coma is a state of prolonged unconsciousness when the patient does not move or respond to a painful stimulus, light, or sound. Causes of coma include head injury, stroke, brain tumour, drugs, alcohol, diabetes mellitus, and infection.

Examination of the skin of a comatose patient may provide information about the cause of coma, and the effects of the coma on the body. Skin examination may provide clues to a pre-existing systemic medical condition that could predispose to coma, such as the skin changes that can occur with longstanding diabetes mellitus, or drug abuse.

Skin colour

Colour changes in the skin may reveal a potential cause of the coma.

  • White or ashy colouring may indicate blood loss or other forms of anaemia.
  • Yellow may indicate jaundice from liver damage.
  • Red skin may indicate an immune-related reaction.
  • Purple or green skin could indicate bruising.

Colourful skin changes and associated swelling provide important clues for cellulitis, venous stasis, or deep vein thrombosis, for example. The rash of meningococcaemia is characteristic.

Skin temperature

Fluctuations in skin temperature may reflect the depth of a coma.

  • Comatose patients with a higher level of consciousness have temperature fluctuations in circadian rhythm, similar to a healthy individual.
  • Patients in a deeper coma have a more constant temperature.
  • Unusually high or low temperature may indicate infection or the loss of the patient’s ability to control body temperature due to brain injury.

Coma blisters

Traditionally associated with barbiturate overdose, coma blisters can develop in association with coma due to other causes such as in a diabetic coma. They are thought to be caused by hypotension-associated necrosis and pressure. Coma blisters appear within 48–72 hours of the onset of coma as multiple, tense, blood-filled blisters at pressure sites. They typically self-resolve after several weeks. Skin biopsy shows a subepidermal blister and sweat gland and sweat duct necrosis. Thrombi in dermal vessels is often a clue the coma is not drug-induced.

Pressure ulcers

Immobile hospitalised patients are at risk for pressure ulcers, including comatose patients who cannot communicate their ischaemic pain. Prevention of pressure ulcer includes limiting pressure, friction, and shear, while managing comorbid conditions that may interfere with wound healing, such as diabetes.

Coma nails

Subungual haemorrhages in fingernails may be noted several weeks after hospital admission for coma. Firm pressure on the nailbed may be used repeatedly during a hospital admission to determine response to pain in comatose patients. 

 

Pressure ulcer

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Related information

 

References

  • Bateman DE. Neurological assessment of coma. J Neurol Neurosurg Psychiatry. 2001;71 Suppl 1(Suppl 1):i13-7. doi:10.1136/jnnp.71.suppl_1.i13. PubMed
  • Blume C, Lechinger J, Santhi N, et al. Significance of circadian rhythms in severely brain-injured patients: A clue to consciousness?. Neurology. 2017;88(20):1933-41. doi:10.1212/WNL.0000000000003942. PubMed
  • Rocha J, Pereira T, Ventura F, Pardal F, Brito C. Coma blisters. Case Rep Dermatol. 2009;1(1):66-70. doi:10.1159/000249150. PubMed
  • Bhattacharya S, Mishra RK. Pressure ulcers: current understanding and newer modalities of treatment. Indian J Plast Surg. 2015;48(1):4-16. doi:10.4103/0970-0358.155260. PubMed
  • Wijdicks EF, Schievink WI. Neurological picture. Coma nails. J Neurol Neurosurg Psychiatry. 1997;63(3):294. doi:10.1136/jnnp.63.3.294. PubMed

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