Management of coma


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Management of coma

  1. 1. Why coma management?• Common medical emergency 3-5%• Large proportion of comatose patient recover• Untreated coma may lead to further brain damage
  2. 2. Check vital signs• Respiration• Pulse, BP,• temperature.
  3. 3. Emergency treatment• Maintain ventilation oxygenation• Maintain circulation• Control seizure• Reduce icp• Maintain temperature• Control hypoglycemia
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. Reduce intracranial pressure• Inj Mannitol 20% 1gm/kg IV fast• Hyperventilatin to bring pCO2 25-30mmHg
  9. 9. Maintain Temperature• Hperthermia: tapid sponging, largectil,• Hypothermia: heating blanket
  10. 10. Is it Coma ?• Posture: loss of erect posture• Eye closed: sleep like state• Lack of responsive ness
  11. 11. Psychogenic coma• Holds eye tight, resist opening• Fixed stare, quick blink• Normal pupil• Normal oculocephalic• Normal oculovestibular• Normal posture, breathing, bp,pulse
  12. 12. Spectrum of Coma• Psychogenic unresponsiveness• Acute confusional state• Locked in syndrome• Akinetic mutism• Persistent vegetative state• Brain death
  13. 13. What causes coma?Metabolic:- Structural:- – Ischemic hypoxic – Supratentorial bilateral – Hypoglycaemic – Unilateral large lesion – Organ failure with transtentorial – Electrolyte disturbance herniation – Toxic – Infratentorial
  14. 14. 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
  15. 15. Supratentorial Lesions • Epidural or Subdural Hematoma • Large Ischemic Infarction • Tumour • Intraparenchymal haemorrhage • Trauma • Abscess
  16. 16. Infratentorial Lesions• Basilar artery thrombosis• Pontine or Cerebellar Hematoma• Ischemic Cerebellar Infarction• Tumour• Abscess
  17. 17. 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
  18. 18. Other symptoms of coma• Yawning • Vomiting – Lateral reticular formation of – Poor localizing value the medulla – Posterior fossa expanding – Projectile ( usually nausea) lesion – Medulloblastoma ependymoma – Medial temporal, third – Raised icp -> compression of ventricular medulla – Basal meningitis• Hiccup – Ivh -> irritating fourth – Medullary lesion in the region ventricle of Third ventricle – Lateral medullary infarct (vestibular
  19. 19. Examination• General physical examination• Evidence of external injury• Colour of skin and mucosa• Odour of breath• Evidence of systemic illness• Heart lung
  20. 20. Neurological examination• Funduscopy• Pupil size and response to light• Ocular movements• Posture and limb movement• Reflexes
  21. 21. CirculationKocher-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
  22. 22. Breathing• Forebrain – Post hyperventilation apnea – Cheyne stoke respiration• Hypothalamus midbrain – Central neurogenic hyperventilation• Basis pontis – Pseudobulbar paralysis of voluntary center
  23. 23. Breathing in coma• Lower pontine tegmentum – Apneustic breathing – Cluster breathing – Short cycle periodic breathing – Ataxic breathing• Medulla – Ataxic breathing – Slow regular respiration – Gasping
  24. 24. 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
  25. 25. Eye movement• Metabolic – Roving eye movement, – Oculocephalic, – Vestibuloocular• Supratentorial – Contralateral conjugate palsy• Thalamus – Upper turn down
  26. 26. Eye movements in Coma• Midbrain – Ipsilateral 3rd• Pontine – Ipsilateral 6th – Ipsilateral gaze palsy – One and half syndrome – Bilateral gaze palsy – Ocular bobbing – Mlf syndrome
  27. 27. Posture• Cerebral hemisphere • Upper brain stem – Decorticate posture – Decerebrate posture• Diencephalon • Pontine supratentorial – Abnormal ext arm – Diagonal posture – Weak flexion leg • Medullary – Flaccidity
  28. 28. 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 – PVcs, VFL, VF
  29. 29. 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
  30. 30. Agitated1. Reassurance2. Narcotics – Small doses administered – Intravenously3. Sedation • Should follow analgesia • Sedation in presence of pain causes agitation, • Titrate intravenously so that agitation is blunted, • Do not induce excessive drowsiness
  31. 31. Agitated patient5. 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
  32. 32. Coma Subsequent management • Eye, mouth, skin • Fluid electrolyte, feeding • Respiration, circulation • Urine, bowel • Stimulation • Infection