coma diah mustika hw,sps,kic intensive care unit of emergency department naval hospital dr ramelan,...

COMA

DIAH MUSTIKA HW,SpS,KIC

INTENSIVE CARE UNIT of EMERGENCY DEPARTMENTNAVAL HOSPITAL dr RAMELAN, SURABAYA

DEFINITIONS

Coma• State of unresponsiveness to external or internal stimuli

in which a patient lies w/ eyes closed unaware of theenvironment

Consciousness

• State of awareness of both the self and the environment

• ARAS : rostral pons,midbrain, thalamus,hypothalamus

• Wakefullness or alertness

• Cerebral cortex andconnection to subcorticalwhite matter

• Attention, memory,motivationand executive function

Arousal

Content

Alert : fully conscious AAlert: Fully conscious

Lethargic: appear somnolent, but may be able to maintainarousal spontaneously or with repeated light stimulation

Obtunded: requires touch or voice to maintain arousal

Stuporous: unresponsiveness from which the individual canbe aroused only by vigorous and repeated stimulus

Comatose: state of unarousable unresponsiveness in whichindividual lies with eyes closed, lacking awareness of selfand environment

Levels of Arousal:

MotorResponse

Example Score

Commands Followssimplecommands 6

LocalizesPain

Pullsexaminer'shandawaywhenpinched

5

WithdrawsfromPain

Pullsapartofbodyawaywhenpinched

4

AbnormalFlexion

Flexesbodyinappropriatelytopain

3

AbnormalExtension

Bodybecomesrigidinanextendedpositionwhenexaminerpincheshim

2

NoResponse Hasnomotorresponsetopinch 1

Eye-Opening .Spontaneous Openseyesonown 4

ToVoiceOpenseyeswhenaskedtoinaloudvoice

3

ToPain Openseyeswhenpinched 2NoResponse Doesnotopeneyes 1

VerbalResponse(Talking) .

Orientated Carriesonaconversationcorrectlyandtellsexaminerwhereheis,whoheis,andthemonthandyear

5

ConfusedConversation

Seemsconfusedordisoriented 4

InappropriateWords Talkssoexaminercanunderstandhimbutmakesnosense

3

SoundsMakessoundsthatexaminercannotunderstand 2

NoResponse Makesnonoise 1

EMERGENT MANAGEMENT

Stabilization:

• Airway– Assess for patency– Assess for ability to protect

• Breathing– Assess ventilation– Assess breathing pattern

• Circulation– Assess measures of cardiac output

• Hyper or hypothermia should reversedappropriately to normothermia

Evaluation:

• History

• Physical Exam

• Laboratory and Imaging Studies

Evaluation—History:

• Rapid initial history:–––––––

Recent history prior to mental status changesPast medical history (seizures)Family history (specifically seizures/neurologic disorders)Trauma ?Febrile ? / Other signs or symptoms of infectionDietExposure to drugs/toxins

• Follow-up with more complete history:

Evaluation—Physical Exam:

• Systemic– Vital Signs– Signs of trauma– Signs of infection– Signs of bleeding– Signs of other systemic illnesses

Evaluation—Physical Exam:

• Rapid Neurologic Exam:– Pupils– Respiratory pattern– Stimuli needed to elicit response– Character of the response

Neurologic Exam—Pupils:

Respiratory patterns:

Location

Hemispheric

Midbrain

Mid/Lower Pons

Low Pons/UpperMedulla

Medulla

PatternCheyne-StokesCentralHyperventilationApneusticClusterbreathing/GaspingAgonal breathing

Posturing:

Decorticate

lesion abovemidbrain

Decerebrate

lesion belowmidbrain

Common etiologies of comaStructural LesionsSupratentorialGeneralized/bilateral

Infectious/positinfectiousEncephalitisAcute disseminated encephalomyelitis

VascularAnoxic – ischmenic encephalopathyMultiple cortical infarctionsBilateral thalamic infarctions

TraumaticDiffuse axonal injuryPenetrating brain injuryMultiple contusions

NeoplasticGlimatosisLeukoencephalopathyMultiple brain metastasesLymphoma

Focal (with mass effect)Intraparenchymal hematomaLarge stroke with edemaAbscessTumor

InfratentorialBrain stem

Pontine hemorrhageBasilar artery thrombisCentral pontine myelinolysis

CerebellumInfraction with edemaHematomaAbscessTumor

Metabolic derangementsHypoglycemiaHyperglycemia (nonketotic hyperosmolar)HyponatremiaHypercalcemiaPanhypopituitarismHyperbilirubinemiaAcute uremia

Diffuse Physiologic Brain DysfunctionStatus epilepticusPoisoningDrug overdoseGas inhalationHypotthermiaBasiliar migraineMalignant neuroleptic syndromeHypoxia

Psychogenic UnresponsivenessCatatoniaConversion disorderMalingeringAdapted from Ziai WC. Coma and altered consciousness. In Bhardwaj A, MirskiMS, Ulatowski JA (eds), Current Clinical Neurology : Handbook of Neurocritical

Care. Totowa, NJ : Humana Press, 2004, pp 1 – 18

Thanks for yourattention