medicine.Coma managment.(dr.muhamad tahir)

ΔMS Ken Uchino, M.D.Assistant Professor of Neurology UPMC Stroke Institute

DEFINITION COMA: the complete absence of awareness of self and the environment even when the subject is externally stimulated

ΔMS Confusion Drowsy—Inability to sustain wakefulness without external stimuli Obtundation—aroused by vigorous stimuli, interacts briefly Stupor—arounsed only by vigorous and repated stimuli, but not interactive Coma

ΔMS IT’S A SPECTRUM: ALERT ”DROWSY” ”OBTUNDED” ”STUPOROUS” COMATOSE ….much better to just describe what you see!

ANATOMY RETICULAR ACTIVATING SYSTEM: – a primitive, evolutionarily conserved diffuse (reticular) network of neurons throughout the brain – some more concentrated areas “nuclei” or “centers” – originates in brainstem – ascends through diencephalon via which it connects to rest of brain

ANATOMY Two major anatomic patterns of coma: 1. Diffuse cerebral injury (2/3) or 2. Focal injury to the brainstem (1/3)

DIFFUSE CEREBRAL INJURY Trauma – Concussion, diffuse axonal injury Vascular – Global hypoxia-ischemia – Hypertensive encephalopathy Infectious – Sepsis – Meningitis, encephalitis Epileptic – Post-ictal state – Non-convulsive status epilepticus

DIFFUSE CEREBRAL INJURY Metabolic: – Electrolyte abnormalities:  pH disturbance  Hyper or hyponatremia  Hyper or hypoglycemia  Hyper or hypocalcemia – Organ failure  liver, kidney – Thiamine or vitamin B12 deficiency – Drug intoxication or withdrawal

FOCAL BRAINSTEM INJURY Direct hit to the brainstem – Brainstem stroke or tumor Secondary pressure onto the brainstem – Trauma  Subdural or epidural hematoma – Vascular  Subarachnoid hemorrhage  Intracerebral hemorrhage – Neoplasm – The mass raises intracranial pressure and herniation onto the brainstem.

Case 1 50 yo man sent confused from homeless shelter. History not obtainable. ? EtOH abuse PE: Afebrile, tachycardic. Mildy hypertensive. Really groggy. When aroused, very confused, dysarthric.

Case 1 CT normal Labs: WBC 15, otherwise CBC, Chem 7, LFTs normal. EtOH level undetcable, Urine tox: negative for drugs of abuse. Presumed dx: toxic encephalopathy, EtOH withdrawal

Case1 Febrile in the evening. The resident attempts to perform LP. After attempt at decubitous position… Attempted sitting up (with help of nurse and attending physician)… Green fluid comes out.

ΔMS H&P 1. Recent events: – When was the patient last seen? – How was the patient discovered? – Were there any preceding neurologic complaints? – Was there any recent trauma or toxic exposure? 2. Medical istory 3. Psychiatric history 4. Medications 5. Use of drugs or alcohol

General Physical Exam Vitals – Is there a fever? – Severe hypertension? Skin – Trauma, jaundice, needle marks Head – Fractures, lacerations Neck (do not manipulate if suspect Fx!) – Stiffness? Neurologic exam…

Coma exam Describe: Observe then stimulate: – Level of consciousness Brain stem Exam – Fundi, Pupils, Corneals, EOM, Gag and cough Extremities

Coma Exam: Level of Consciousness Awake “Opens eyes to voice,” “grimaces to pain,”… Localizes pain—pain where ?(central vs. peripheral) Any abnormal response? Patterned response? – Flexor posturing (Decorticate) – Extensor posturing (Decerebrate) – Myoclonus? Respiratory pattern? – “Riding the vent” vs. overbreathing

Respiration Cheyne- Stokes pattern – diencephalic/ diffuse – CHF hyperventilation – midbrain apneustic pattern – pons ataxic respiration – medulla …interesting, but not really useful in the field!

Testing LOC First, a verbal command: – Specific command (hard): “Show me two fingers!”  not “squeeze my hand” – Midline command (easier): “Open your eyes”  eye lid apraxia? Try it again with a noxious stimulus

Testing LOC: Noxious – Head: stimulus  ear pinch, cotton swab to nares, supraorbirtal ridge pressure, pin to nares – Body  Sternal rub, shoulder pinch  Areolapossibly the most sensitive spot you can find…It also helps you identify the malingering patients. – Extremities  Pinch arm or calf, Nailbed pressure, plantar stimulation Response  Localization  Withdawal  Flexor (decorticate) posturing  Extensor (decerebrate) posturing

Posturing Extensor posturing (Decerebrate) – Hips and shoulders extend, adduct, and internally rotate – Knees and elbows extend – Forearms hyperpronate, Wrists and fingers flex – Feet plantar flex and invert – Trunk extends, Head retracts Flexor posturing (Decorticate) – Shoulders adduct, internally rotate, and flex slightly; elbows flex; forearms pronate; and wrists and fingers flex – Lower extremities extend, adduct, and internally rotate – Hip, knee, and ankle may flex in a spinal reflex known as triple flexion

A picture speaks…• It means that the patient is not conscious.• The cortex isn’t communicating.• It’s not well localizing.

Brains stem reflexes: pupils critical in distinguishing metabolic from structural etiologies of coma

Brainstem reflexes: pupils Dilated, unreactive pupils – third nerve compression – sympathetic agonist drugs (cocaine) – cholinergic antagonists (atropine) Small reactive pupils +/- Horner’s syndrome – hypothalamus/diencephalon injury – damage to sympathetic input – opiates, cholinergic agonist drugs

Brainstem reflexes: pupils fixed midposition pupils – midbrain – i.e. loss of sympathetic and para- sympathetic inputs (Edinger- Westphal) small unreactive/ minimally reactive pupils – pons, cholinergic poisoning

Brain stem reflexes: extraocular movements Horizontal conjugate gaze is mediated by: – Frontal eye fields – Pontine gaze centers In unresponsive patients, conjugate eye movments can be elicited by: – Oculocephalic reflex (Doll’s eye) – Oculovestibular reflex (Cold water calorics)

Brain stem reflexes: EOM First, observe at rest – Roving – Not moving – Gaze deviation  Hemispheric lesion: “eyes look at the lesion”  Pontine damage: “eyes look away from the lesion”  Seizure: “eyes look away from the lesion.”

Brainstem reflexes: EOM Conjugate – A good sign, but do they move appropriately? Dysconjugate – A bad sign, but why?  Just relaxed muscles?  Impaired EOM?

Brainstem reflexes: EOM Next, try the reflexes: 1. Oculocephalic (aka Doll’s eye) reflex: – Presence indicates that the brainstem is intact 2. Coculovestibular (caloric) reflex: – Tonic deviation towards the cold ear

Brainstem reflexes Corneal Reflexes: – CN 5 & 7 – pontine lesion Gag Reflex: – afferent component  IX – efferent component X

Brainstem reflexes EYE Pupils: – II in – III out EOM: – VIII in – III, (IV), VI out Corneals: – V in – VII out Gag: – IX in – X out

Extremities Reflexes – Deep tendon reflexes – Response to noxious stimuli:  Is it a reflex or withdrawal?  Plantar response—triple flexion

Glasgow Coma ScaleEye OpeningNone 1To Pain 2To Speech 3 Best Verbal ResponseSpontaneous 4 None 1Best Motor Response Incomprehensible sounds 2None 1 Inappropriate words 3Extension (at elbow) 2 Confused 4Abnormal Flexion 3 Oriented 5Withdrawal 4Localizes pain (attempts to 5remove stimulus) Total Score = 3-15Obeys commands (simple 6commands)

Case 2 (JJ) 78 yo woman stopped talking and had right sided weakness. On the way to the hospital, she vomited. Became unresponsive. PMH: macular degeneration, anxiety. Pt was intubated in the ER. Received lasix for HTN of 218/98.

 BP 180/90 P 84 afebrile General PE: unremarkable, except intubated. Neurologic: No spontaneous movements or eye opening. Not following commands. Noxious stimuli: – She localizes pain in the left UE. She has purposeful movement in the left upper extremity (squeezing hand sponaten.). – On the right side, extensor posturing to pain on the right UE and triple flexion in the right lower extremity. Brain stem: – Her pupils are 2 mm and reactive. She has left gaze preference, but has spontaneous eye movements. Visual field is difficult to assess. She has gag reflex intact.

CATEGORIZE Nonfocal exam with brainstem intact – Reactive pupils, full eye movements, symmetric motor responses. – Suggests diffuse cerebral damage. Focal hemispheric signs – Contralateral hemiparesis, gaze paresis – Suggests structural CNS lesion Focal brain stem signs – Abnormal pupil reactivity, cranial nerve signs, motor posturing. – Suggests brainstem lesion

MANAGEMENT In the case of a diffuse cerebral injury with no known cause…give the coma “cocktail”: – THIAMINE 100 mg IV – 50% DEXTROSE 50ml IV – NALOXONE (Narcan) 0.4-0.8 mg IV – (FLUMAZENIL (Romazicon) 0.2-1.0 mg IV)

MANAGEMENT In the case of focal hemispheric or brainstem signs, obtain neuroimaging.. – CT – MRI And look for signs of increased intracranial pressure

Case 3 (CM) 75 yo F found down by husband. She has left hemiparesis, dysarthric. C/o HA. PMH: GERD, no HTN SH: Husband: she drinks and smokes as much as she can. PE: BP 106/90 A+O x3. Follows commands. Speech fluent, but dysarthric. She has left neglect. Pupils 63 mm. Left VF cut. Corneal and gag reflexes present. Facial sensation is diminished on the left. Right eyelid droop (old). Flaccid hemiplegia. Sensation: neglect. Deep tendon reflexes 1 throughout. Toes going up bilaterally.

Right thalamic ICH & IVHCT: on Nov 5at 1450

Case 3 Day 2 BP 169/94 No eye opening to stimuli. Not following commands. Eyes downward and to the left. Pupils 3mm reactive. Corneal reflexes present. Left hemiplegic. RUE purposeful movement. RLE withdrawal. Bilateral upgoing toes.

↑ICH & hydrocephalus• CT: Nov 6 at 4:50 am• Subsequently Intubated• Ventriculostomy

Case 3 Day 3 ICP shot up early morning. Got head CT: Exam off propofol x 5min: LUE extension and RUE flexion to pain centrally as well as peripherally. Triple flexion in LE bilaterally. Pupils 2mm reactive. Left gaze deviation but some spontaneous roving movements. Corneal reflex intact.

Case 3 Day 4 Off propofol for 24 hours BP 148/68 P 120 RR 14/13 Unresponsive to sound or pain Pupils fixed at 4mm, corneal reflexes present. Absent gag reflex. Triple flexion in LE. Pt expired later that day.

Herniation Syndromes Central Transtentorial – paratonic rigidity of lower extremities – pinpoint pupils (sometimes) – hyperreflexia/ spontaneous triple flexion responses – waning level of consciousness – sudden cardiac or respiratory arrest/ death

Herniation Syndromes

Herniation Syndromes Lateral Transtentorial/Uncal: – most common in those with temporal lobe masses (tumor, hematoma,…) – ipsilateral dilated pupilthen bilateral – hyperreflexia/ spasticity – ipsilateral hemiplegia (Kernohan’s notch) – hemianopsia (PCA infarct) – brainstem compression/ death

Herniation Syndromes SUBFALCIAL HERNIATION – ipsilateral and/or contralateral paratonic rigidity – LE paralysis (once completed) – akinetic mutism (bilateral ACA) TONSILLAR HERNIATION – downward cerebellar herniation – nausea, vomiting, hyperreflexia – sudden respiratory arrest

Herniation Syndromes Upward cerebellar herniation: – nausea, vomiting, hyperreflexia – SCA infarction syndrome – hyperventilation – brainstem compression/ coma/ death Transcranial Hernation: – skull fracture, craniotomy – ischemia of adjacent cortex (strangulation)

Case 4 35 yo man unresponsive. Pt was just booked for some incident. At police station, found with empty pill bottle. Pt unresponsive. No known medical history.

Case 4 CT head normal Labs: – Urine tox for drugs of abuse normal (opiates, amphetamines, cocaine, tricyclics), salicylate and acetaminophen levels undetectable. PE: – Vitals normal – General exam: shackled to stretcher  Blood in back – Unresponsive to voice, pain. Brainstem reflexes intact. Extremity reflexes in tact.

Techniques Let arm drop on face Tickle nares Surprise the patient

Case 4 Wouldn’t let eyes be opened ER residents had attempted LP without lidocaine. (The blood in back). He only flinches with needle in his back. I further macerate his back and succeed in getting CSF—normal Angry man next morning.

Case 5 40 yo woman from rural Washington state Presents to local ER c/o “throat swelling.” She also c/o blurred vision. The exam is reported to be fairly unremarkable initially. But in the ER she worsens and develops respiratory arrest. No signficant past medical history. No asthma or allergies.

Case 5 She is intubated, given steroids for presumed allergic reaction or angioedema. She is transferred to Seattle. In medical ICU she is on vent. She is treated for aspiration pneumonia, reactive airways. She remains unresponsive. Comatose. Never wakes up. Several days later neurology is consulted for post- anoxic encephalopathy. Is she going to wake up?

Case 5 Exam: Vitals normal. Riding the vent. – Unresponsive to pain, sound. – Pupils unreactive, absent corneals, cold calorics absent, no gag. Areflexic in extremities CT of head: normal. Is she brain dead?

Brain Death: the complete and irreversible cessation of all brain function absent pupillary responses (fixed, midposition) absent oculocephalic responses absent corneals, gag absent calorics response absent motor response absent respiration (pCO2>60)

Brain Death: Necessary Tests APNEA TEST – preoxygenate with 100% O2 – maintain O2 through ETT with cannula etc. – two minute duration – pCO2 of 60mmHg or higher adequate COLD WATER CALORICS – never do in a noncomatose person – ice water 30cc to each ear – wait 2 minutes for response before other side

Case 5 Wait, she moves her toe!

Brain Death: Pitfalls no drugs or hypothermia to explain a precondition of diagnosis absent pupillary responses – anticholinergic drugs, especially atropine in cardiac arrest – NM blockade – preexisting eye disease absent oculocephalics – ototoxic/ vestibular toxins

Brain Death: Pitfalls apnea – NM blockade – post- hyperventilation – phrenic nerve palsies/ diaphragm paralysis no motor activity – NM blockade – locked in syndrome – sedatives

Brain Death: Confirmatory Tests Confirmatory tests are NOT necessary for the diagnosis. Tests necessary if the checklist incomplete. – Trauma, hemodynamic instability Tests: – EEG with special array, sensitivity settings  ICU artifact can create problems – cerebral blood flow (Nuc Med) – Transcranial Doppler ultrasound – Evoked potential studies notlegally required to render futile care to a dead person

Summary Get good History from surrogate Examine Is it focal or diffuse?

medicine.Coma managment.(dr.muhamad tahir)

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