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
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