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approachtocoma-231117212500-54cd6ca4
approachtocoma-231117212500-54cd6ca4
approachtocoma-231117212500-54cd6ca4
COMA
Presenter :- Dr. Wondwosen M. (R1)
Moderator:- Dr. Desalegn Y. (Assistant Professor & Consultant Neuologist)
Arsi University
Dep’t Of Internal Medicine
1st August, 2023
OUT LINE
Introduction
Anatomy of Consciousness
Coma Mimics
Causes of Unconsciousness
Approaches to Unconscious Patients
Investigations
Management
Prognosis
References
Introduction
• Coma is among the most common neurologic emergencies encountered in
general medicine and requires an organized approach
• Consciousness: a state of awareness of self and Environment
• Levels of consciousness are classified into four levels, these being alert,
drowsy, stupor, and coma
• Drowsiness simulates light sleep and is characterized by easy arousal and
the continuation of alertness for a brief period
• Stupor refers to a state of near unresponsiveness that needs strenuous or
repeated stimulus to elicit a response
• Coma is a deep sleep like state with eyes closed, from which the patient
cannot be aroused, failure in responding to external stimuli,incapability in
responding to inner needs, and incompetence of interaction with the
environment
Anatomy of Consciousness
• Arousal requires the interplay of both: ARAS and The cerebral hemispheres
• There are also Several conditions that render patients unresponsive and
simulate coma :-
– Persistent vegetative state
– Locked in syndrome
Persistent Vegetative State
Ventral brainstem destruction sparing the RAS renders the patient mute and
quadriplegic but not comatose
Patient is awake but speechless and motionless, with little response to stimuli
Lesion usually involves the mid pons and results in paralysis of facial movement and
horizontal gaze
There is preservation of vertical eye movements and the patient may be able to
blink
Sensory pathways, hearing and vision are largely spared
The principal cause of locked-in syndrome is brainstem stroke (86%), but it may
also occur after trauma (14%)
Table: Behaioral state confused with Coma
Abulia severe aphaty, patient neither speaks no moves Bilateral frontal medial
spontaneously
Pseudocoma Feigned coma
Brain Death
• Brain death is a condition in which systemic circulation is preserved but complete
and irreversible loss of cerebral and brainstem function
• Common causes : cerebral anoxia, ICH, aneurysmal SAH and TBI
• The diagnosis of brain death should ideally be after
– Identified underlying Cuase
– Exclusion of Confounding Medical conditions
– Neurologic examination must demonstrate
• Coma
• No brain-generated response to external stimuli
• Absent brainstem reflexes
• An apnea test
The Apnea Test
Prerequisites
Steps
• Disconnect the patient from the ventilator
• PaCO2 b/n 35 mmHg and 45 mmHg • Deliver O2 at 6 L/min through a catheter
• SBP ≥100mmHg with/out vasopressors advanced through the tracheal tube until
close to the carina
• Administer 100% oxygen for at least 10 • Look carefully for any respiratory mov’ts
minutes (ideal PaO2 >200 mmHg with while monitoring pulse oximetry and BP
• If no respiratory movements after ≈(8-10)’ ,
PEEP ≤ 5 cmH2O) obtain arterial blood gases
• Absence of clinical signs of • Apnea is established if PaCO2 ≥ 60 mmHg
• The more common and important one are central transtentorial, lateral
• Traumatic brain injury (TBI) is the most common cause of coma in children
• Hypoxic-ischemic encephalopathy (HIE) and stroke are the most common cause
Initial assesssment
• Three requirements for rescue treatments remain a priority for the initial assessment
of unconscious patients
Airway
Breathing
Circulation
– establishing IV access
– Blood should be withdrawn: estimation of glucose , other biochemical parameters , drug screening
History
The history will often be limited, sources may be relatives, friends,or witnesses if available
– recent injuries
• Examinations for nuchal rigidity should not be performed unless neck damage has
been excluded
Physical Examination
Vital Signs
• Blood Pressure
– High: hypertensive encephalopathy, elevated ICP, or a massive intracranial hemorrhage
• Pulse
– Bradycardia: brain tumors, opiates, ICT, myxedema
• Respiratory rate
• Temperature
circulatory failure
Physical Examination
• Skin
– Cherry-red: CO poisoning
• Odour Of Breath
– Acetone: DKA
– It can detect locked-in syndrome and is superior to the GCS due to the evaluation of brainstem
reflexes, breathing patterns, and the ability to recognize different stages of herniation
Four Score
Brainstem Reflexes
– Pupillary reflex
– Ocular movements
– Corneal reflex
– Respiratory pattern
• As a rule, coma due to bilateral hemispheral disease preserves these brainstem activities
Pupillary Reflex
• The pupils become small symmetrical & intact light reflex in Metabolic Uncsc
• Pinpoint pupils with poor reaction to light suggest a pontine tegmental lesion
The eyes look toward a hemispheral lesion and away from a brainstem lesion
Oculocephalic Reflexes (Doll's eye movement)
• The intact reaction of oculocephalic reflexes (Doll’s eye movement) consists of the
deviation of both ocular globes towards the opposite direction of cephalic turning
• Once an unconscious patient does not express these symptoms, then a lesion must be
• If the connective pathways b/n the afferent and efferent arms in the pons & medulla
become interrupted in unconscious patients, the doll’s eyes reflex will also be absent
Oculovestibular Reflex
• Irrigating ear with cold water/saline introduces ipsilateral deviation of both eyes
with contralateral fast phase nystagmus lasting for one to two minutes
• Metabolic diseases & Structural diseases of the brainstem often give rise to
abnormal responses
patients implies an intact connection between the pons and the midbrain
Oculovestibular reflex
Corneal reflex
• The corneal reflex indicates the degree of intactness of the pathway from the
ophthalmic branch of 5th CN through the pons to the 7th & facial muscles
• Gently touching the cornea with a thin wisp of sterile cotton will lead to
– involuntary closure of the ipsilateral eye
– closing of the contralateral eye (consensual response)
• Bilateral loss of the corneal reflex with light unconsciousness indicates the influence
of drugs or local anesthetics in both eyes
• The unilateral loss of the corneal reflex indicates a focal neurological disease
• The existence of the corneal reflex in unconscious patients indicates that the lesion is
likely located outside the pons
Respiratory patterns
in Metabolic disorders
• Resting posture
Head and eye deviation to one side, with contralateral hemiparesis, suggests a
or brainstem
Adventitious movements
• Helps to differentiate metabolic from structural
Myoclonic jerk
Rhythmic myoclonus
Cerebellar fits
More subtle twitches, random or sustained
• Sensory examination
Look for asymmetry for painful stimuli
• Meningeal sign
Sign of lateralization
• Unequal pupils
• Deviation of the eye to one side
• Facial asymmetry
• Turning of the head to one side
• Unilateral hypotonic/hypertonia
• Asymmetric deep tendon reflex
• Unilateral extensor plantar response
• Unilateral focal or jacksonian fits
Posturing
Decorticate rigidity
Flexion of the elbows and wrists and
supination of the arm
Bilateral damage rostral to midbrain
Decerebrate rigidity
Extension of the elbows and wrists
with pronation
Damage to motor tracts in the
midbrain or caudal diencephalon
Investigation
• Laboratory studies remain primary for patients with potential diffuse lesions
– cerebrospinal fluids (CSF)
– serum glucose
– complete blood count (CBC)
– calcium, sodium, potassium, magnesium
– arterial blood gases and pH,
– liver and renal functions
– drug levels, and blood for metabolic panels and
– blood culture
Investigation
General Mgm’t
• The ABCDE (A for airway, B for breathing, C for circulation, D for disability, and E
for exposure) approach to resuscitation must be applied
• The establishment of a clean airway includes
– maintaining an initial lateral position
– suction to remove secretions
– endotracheal intubation
– mechanical ventilation if patients cannot protect against aspiration, hypoxia, or
hypoventilation
Management
• The patients’ bowels, bladder, hygiene & skin care should not be ignored
Monitoring and Management of ICP
ICP Monitors
General Care
Monitoring and Management of ICP
• First-line therapies
Emergency
Neurological Life Support • Noninvasive maneuvers-
(ENLS) repositioning, ventilator changes,
ICP treatment algorithm
sedation, analgesia
• Second-line therapies
• Osmotic agents
• Hyperventilation
• CSF diversion
• Third-line therapies
• Metabolic suppression with
anesthetic agents
• Induced hypothermia
• Surgical decompression
Prognosis
• In general, for patients who remain comatose for more than four weeks, the chance