Management of coma and altered sensorium 19.4.01

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Management of coma and altered sensorium 19.4.01

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

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