management of coma
TRANSCRIPT
![Page 1: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/1.jpg)
![Page 2: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/2.jpg)
Why coma management?
• Common medical emergency 3-5%• Large proportion of comatose patient
recover• Untreated coma may lead to further
brain damage
![Page 3: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/3.jpg)
Check vital signs
• Respiration• Pulse, BP, • temperature.
![Page 4: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/4.jpg)
Emergency treatment
• Maintain ventilation oxygenation• Maintain circulation• Control seizure• Reduce icp• Maintain temperature• Control hypoglycemia
![Page 5: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/5.jpg)
Maintain ventilation
• Insert oral airway• Clean oropharyngeal secretion• Insert cuffed endotracheal tube if apnea,
hypoventilation or liable to aspirate• Mechanical ventilation if apnea or raised
intracranial pressure
![Page 6: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/6.jpg)
Draw Blood for
• Start venous line• Complete blood count, MP, B.sugar• Blood urea, s. creatinine,
s.electrolyte• Blood gases, ALT, AST• Give 25% 100ml glucose with
100mg of thiamine
![Page 7: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/7.jpg)
Maintain circulation
• If hypotenstion ( <90mmHg systolic)– Replace fluid:
• Saline if hyperglycemia or suspected stroke, diabetes
• Dextrose saline or isolyte if undiagnosed– Vasopressor if low systolic pressure inspite of
fluid• Hypertension: Betablocker, Nitroglycerine
or Nitropruside
![Page 8: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/8.jpg)
Control Seizure
• Inj Lorazepam 4mg or Midazolam 5mg IV slowly
• Inj Diazepam 10-20mg iv slowly• Inj Phenytoin 15-20mg/Kg 50mg/min IV• Inj Phenobarb 15-20mg/Kg 50mg/min IV• Inj Sodium valproate 200-400mg IV
![Page 9: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/9.jpg)
Reduce intracranial pressure
• Inj Mannitol 20% 1gm/kg IV fast
• Hyperventilatin to bring pCO2 25-30mmHg
![Page 10: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/10.jpg)
Maintain Temperature
• Hperthermia: tapid sponging, largectil,
• Hypothermia: heating blanket
![Page 11: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/11.jpg)
Is it Coma ?
• Posture: loss of erect posture
• Eye closed: sleep like state
• Lack of responsive ness
![Page 12: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/12.jpg)
Psychogenic coma
• Holds eye tight, resist opening• Fixed stare, quick blink• Normal pupil• Normal oculocephalic• Normal oculovestibular• Normal posture, breathing, bp,pulse
![Page 13: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/13.jpg)
Spectrum of Coma
• Psychogenic unresponsiveness• Acute confusional state• Locked in syndrome• Akinetic mutism• Persistent vegetative state• Brain death
![Page 14: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/14.jpg)
What causes coma?
Metabolic:-– Ischemic hypoxic– Hypoglycaemic– Organ failure– Electrolyte disturbance– Toxic
Structural:-– Supratentorial bilateral– Unilateral large lesion with transtentorial
herniation– Infratentorial
![Page 15: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/15.jpg)
Metabolic encephalopathy
• Confusional state -> coma • No focal neurological sign• No neck stiffness• Normal brainstem reflexes• Coarse tremor 8-10hz• Multifocal myoclonus
• Asterixis• Generalized/periodic myoclonus
![Page 16: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/16.jpg)
Supratentorial Lesions
• Epidural or Subdural Hematoma • Large Ischemic Infarction• Tumour• Intraparenchymal haemorrhage• Trauma• Abscess
![Page 17: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/17.jpg)
Infratentorial Lesions
• Basilar artery thrombosis• Pontine or Cerebellar Hematoma• Ischemic Cerebellar Infarction• Tumour• Abscess
![Page 18: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/18.jpg)
History
• Circumstances and temporal profile• Of the onset of coma• Details of preceding neurological• Symptoms headache, weakness seizure• Any fall• Use of drug and alcohol• Previous medical illness liver,kidney• Previous psychiatric illness
![Page 19: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/19.jpg)
Other symptoms of coma
• Yawning– Poor localizing value
– Posterior fossa expanding lesion
– Medial temporal, third ventricular
• Hiccup– Medullary lesion in the region of Third ventricle
• Vomiting– Lateral reticular formation of the medulla– Projectile ( usually nausea)– Medulloblastoma ependymoma– Raised icp -> compression of medulla– Basal meningitis– Ivh -> irritating fourth ventricle– Lateral medullary infarct (vestibular
![Page 20: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/20.jpg)
Examination
• General physical examination• Evidence of external injury• Colour of skin and mucosa• Odour of breath• Evidence of systemic illness• Heart lung
![Page 21: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/21.jpg)
Neurological examination
• Funduscopy• Pupil size and response to light• Ocular movements• Posture and limb movement• Reflexes
![Page 22: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/22.jpg)
Circulation
Kocher-Cushing response - rise in BP-
>bradycardia due to rise in ICP ->
compression of floor of the iv ventricle fall
in BP and tachycardia usually terminal
event due to medullary failure
![Page 23: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/23.jpg)
Breathing
• Forebrain– Post hyperventilation apnea– Cheyne stoke respiration
• Hypothalamus midbrain– Central neurogenic hyperventilation
• Basis pontis– Pseudobulbar paralysis of voluntary
center
![Page 24: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/24.jpg)
Breathing in coma
• Lower pontine tegmentum– Apneustic breathing– Cluster breathing– Short cycle periodic breathing– Ataxic breathing
• Medulla– Ataxic breathing– Slow regular respiration– Gasping
![Page 25: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/25.jpg)
Pupil
• Diencephalic (metabolic) Small reactive• Midbrain tectal Midsize,fixed• Midbrain nuclear Irregular pear shaped• 3rd nerve Fixed widely dilated• Pontine Pinpoint reactive• Opiate Pinpoint• Organophosphorus Small• Atropine Wide dilated
![Page 26: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/26.jpg)
Eye movement
• Metabolic – Roving eye movement,– Oculocephalic,– Vestibuloocular
• Supratentorial – Contralateral conjugate palsy
• Thalamus– Upper turn down
![Page 27: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/27.jpg)
Eye movements in Coma
• Midbrain– Ipsilateral 3rd
• Pontine– Ipsilateral 6th– Ipsilateral gaze palsy– One and half syndrome– Bilateral gaze palsy– Ocular bobbing– Mlf syndrome
![Page 28: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/28.jpg)
Posture
• Cerebral hemisphere – Decorticate posture
• Diencephalon supratentorial – Diagonal posture
• Upper brain stem – Decerebrate posture
• Pontine– Abnormal ext arm– Weak flexion leg
• Medullary– Flaccidity
![Page 29: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/29.jpg)
ECG changes in coma
(SAH, ICH, INFARCT)– Tall T, prolonged QT– Q wave with st depression– SVT, AF, AFL– Sinus bradycardia,arrest, nodal rhythm– A-V block or dissociation– PVc's, VFL, VF
![Page 30: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/30.jpg)
Further investigation
• CSF examination: neck stiffness without localizing sign
• CT scan/ MRI: Focal neurological sign or before LP
• X-ray chest: Aspiration, chest infection, heart size
• Ultrasound abdomen: Liver, kideny, bladder
![Page 31: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/31.jpg)
Agitated
1. Reassurance
2. Narcotics– Small doses administered– Intravenously
3. Sedation• Should follow analgesia• Sedation in presence of pain causes agitation,• Titrate intravenously so that agitation is blunted,• Do not induce excessive drowsiness
![Page 32: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/32.jpg)
Agitated patient
5. General management• Face a window for day/night orientation• Clock, calendar• Have friend or family member stay with patient• Light the room if illusions, paranoia occur at night• Provide eyeglasses, hearing aids• Have staff identify themselves to patient• Explain all procedures• Provide radio, reading, TV
![Page 33: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/33.jpg)
Coma Subsequent management
• Eye, mouth, skin• Fluid electrolyte, feeding• Respiration, circulation• Urine, bowel• Stimulation• Infection
![Page 34: Management of coma](https://reader036.vdocuments.net/reader036/viewer/2022062307/554b29d0b4c905a2058b4a19/html5/thumbnails/34.jpg)