1.05 Hysterical Coma or Seizure
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agk's Library of Common Simple Emergencies

Presentation
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The patient is unresponsive and brought to the 
emergency department on a stretcher. There is 
usually a history of recent emotional upset--an 
unexpected death in the family, or breakup of a 
close relationship. The patient may be lying 
still on the stretcher or demonstrating bizarre 
posturing or even seizure-like activity. The 
patient's general color and vital signs are 
normal, without any evidence of airway 
obstruction. 

Commonly, the patient will be fluttering his 
eyelids or will resist having his eyes opened. 
A striking finding is that the patient may hold 
his breath when the examiner breaks an ammonia 
capsule over the patient's mouth and nose (real 
coma victims usually move the head or do 
nothing). A classic finding is that when the 
patient's apparently flaccid arm is released 
over his face, it does not fall on the face, 
but drops off to the side. The patient may show 
remarkably little response to painful stimuli, 
but there should be no true focal neurologic 
findings and the remainder of the physical exam 
should be normal.

What to do:
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- Do a complete physical exam. Patients some- 
   times react with hysterical coma under 
   stress of illness or injury.
- When there is significant emotional stress 
   involved, administer a mild tranquilizing 
   agent such as hydroxyzine pamoate (Vistaril) 
   50-l00mg im.
- Do not allow any visitors and place the 
   patient in a quiet observation area, 
   minimizing any stimulation until he 
   "awakens." Check vital signs every 30 
   minutes.
     o If there is a question of a generalized 
       seizure, verify with a lactate level or 
       blood gas that shows metabolic acidosis.
- When the patient becomes more responsive, 
   re-examine him, obtain a more complete 
   history, and offer him followup care, 
   including psychological support if appro- 
   priate.
- If the patient is not awake, alert, and 
   oriented after about 90 minutes, begin a 
   more comprehensive medical workup.

What not to do:
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- Do not get angry with the patient and torture 
   him with painful stimuli in an attempt to 
   make him "wake up."
- Do not perform an expensive workup routinely.
- Do not ignore or release the patient who has 
   not fully recovered. Instead, he must be 
   fully evaluated for an underlying medical 
   problem, which may require hospital admiss- 
   ion.

Discussion
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True hysterical coma is substantially an 
unconscious act that the patient cannot 
control. Antagonizing the patient often 
prolongs the condition, while ignoring him 
seems to take the spotlight off his peculiar 
behavior, allowing him to recover. Some 
psychomotor or complex partial seizures are 
difficult to diagnose with their dazed 
confusion or fuge-like activity, and might be 
labeled hysterical. If the diagnosis is not 
obviously hysteria, the patient might need an 
EEG during sleep and deserves a referral to a 
neurologist.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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