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Coma Bp

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Coma Bp

  1. 1. MANAGEMENT OF UNCONSCIOUS PATIENT DR. B. PRAKASH. Prof. M.B. PRANESH DEPT. OF NEUROLOGY KG HOSPITAL AND POSTGRADUATE INSTITUTE, COIMBATORE – INDIA
  2. 2. INTRODUCTION <ul><li>Unconscious patient makes everybody anxious </li></ul><ul><li>Requires structured way of approach </li></ul><ul><li>Should act Urgently / Appropriately / Accurately </li></ul><ul><li>Conscious> Drowsy> Unconscious> ?Death / Permanent Brain Damage </li></ul>
  3. 3. STAGES OF CONSCIOUSNESS <ul><li>Conscious: Awareness of self and surroundings. </li></ul><ul><li>Clouding of Consciousness: Reduced attention span with irritability. </li></ul><ul><li>Confusion: Mild lowering of consciousness. </li></ul><ul><li>Lethargy : Drowsy but arousable. </li></ul><ul><li>Obtundation: Drowsy, slow reaction, gives appropriate answers, back asleep on leaving alone. </li></ul><ul><li>Stupor: Roused by vigorous repetitive stimuli, moans without proper answering. </li></ul><ul><li>Light coma: Unarousable, disorganized primitive motor responses. </li></ul><ul><li>Deep Coma: Absence of response to most painful stimuli. </li></ul>
  4. 4. Eye opening 4 Spontaneous 3 To speech 2 To pain 1 None Best motor response 6 Obeying 5 Localizing pain 4 Withdrawal 3 Abnormal flexing 2 Extensor response 1 None GLASGOW COMA SCALE Best verbal response 5 Oriented 4 Confused conversation 3 Inappropriate words 2 Incomprehensible sounds 1 None USED MOSTLY FOR HEAD INJURY PATIENTS RATHER THAN STROKE (HEMIPLEGIA,APHASIA)
  5. 5. Algorhythm COMA Airway/?Intubate IV Line CFCD Tests-Eme History-Eme CBC, ESR Sugar,RFT ABG,Lytes CXR,ECG Ca,Mg, Toxic Scr’n TRAUMA CT Scan No Trauma Neu.Surg Stiff Neck CT Scan Normal SAH LP Meningitis Toxin Alc->Thiamine 100mg / 50% Dextose 50 ml Opiate -> Inj.Naloxone 0.4-0.8mg IV BenzDia ->Inj.Flumazenil 0.2-1 mg IV Others -> Stomach wash / Antidote / Sympt Supple CNS Exam Normal Lateralising Metabolic CT Scan
  6. 6. SELECTIVE HISTORY TAKING <ul><li>Friend /Relative /Observer </li></ul><ul><li>When was he Last seen? </li></ul><ul><li>How was he discovered? </li></ul><ul><li>What is the mode & evolution of Coma ? </li></ul><ul><li>What are the past Illness? </li></ul><ul><li>What drugs he is on? </li></ul><ul><li>Is any past mental history? </li></ul><ul><li>Trauma </li></ul><ul><li>Drug / Toxins </li></ul><ul><li>Head ache </li></ul><ul><li>Vomiting </li></ul><ul><li>Seizures </li></ul><ul><li>Giddiness </li></ul><ul><li>Fever </li></ul><ul><li>Chest pain </li></ul>
  7. 7. SELECTIVE EXAMINATION <ul><li>VITAL SIGNS: </li></ul><ul><li>HTN – Structural /HT.E </li></ul><ul><li>Hypo – Shock </li></ul><ul><li>SKIN : </li></ul><ul><li>Trauma / Needle Marks </li></ul><ul><li>Rashes / Cherry redness </li></ul><ul><li>Jaundice </li></ul><ul><li>BREATH: </li></ul><ul><li>Alcohol /Acetone </li></ul><ul><li>Fetor Hepaticus </li></ul><ul><li>HEAD </li></ul><ul><li>Hematoma/#/Lacer’ns </li></ul><ul><li>ENT: </li></ul><ul><li>CSF otorrhea/Rhinorrhea </li></ul><ul><li>Hemotympanum </li></ul><ul><li>Tongue Biting </li></ul><ul><li>NECK: </li></ul><ul><li>Do not Move if injured </li></ul><ul><li>Neck Stiffness (Meningitis / SAH) </li></ul>
  8. 8. Gen. Phy. Exam <ul><li>Fever: Syst infection / Meningitis / Encephalitis </li></ul><ul><li>Hyperthermia: Heat stroke / Anticholinergic intoxcn. </li></ul><ul><li>Hypothermia : Cold exp / Alcohol / Barb /Phenoth’z </li></ul><ul><li>Sedative/ Hypo Glycemia/ HypoThyroid/ Per.cir.Fail </li></ul><ul><li>Tachypnea : Acidosis / Pneumonia </li></ul><ul><li>Aberrant Respiratory Patterns: BS disorders </li></ul><ul><li>Marked HTN : HT.E / SAH / ICP / Head injury </li></ul><ul><li>Hypotension : Alcohol / Barb / Int.bleed / AMI / Sepsis / HypoThyroidism / Addison’s crisis </li></ul><ul><li>Petechiae: TTP/ Meningococcemia/ Bld’g Diathesis </li></ul>
  9. 9. NEUROLOGIC EXAMINATION <ul><li>1. Gen. Appearance </li></ul><ul><li>2. Level of Cons’ss </li></ul><ul><li>3. Respiration </li></ul><ul><li>4. Fields </li></ul><ul><li>5. Fundi </li></ul><ul><li>6. Corneal Reflex </li></ul><ul><li>To asses the Depth of COMA </li></ul><ul><li>To localize/Lateralize the lesion </li></ul>7.Gag Reflex 8.Pupils 9.Ocular Movements 10.Motor Response 11.Sensory Resp’se 12.Reflexes
  10. 10. NEU.EXAM-1.GEN.APPEAR’CE <ul><li>Open Eyelids / Slack Jaw – Deep Coma </li></ul><ul><li>Head & Gaze deviation – Ipsi.Hemi.Lesion </li></ul><ul><li>Myoclonus –BS Lesion / Metabolic </li></ul><ul><li>Focal Seizures – Contra.Lesion / Hyperglycemia </li></ul>NEU.EXAM- 2.LEVEL OF CONS. <ul><li>Document the response to specific Stimulus </li></ul><ul><li>Quantify with Glasgow Coma Scale </li></ul>
  11. 11. NEU.EXAM- 3.RESPIRATION. <ul><li>Depressed – Any deep Coma </li></ul><ul><li>Chyne-stokes – Bihemisp / Metabolic </li></ul><ul><li>Hypervent’n – Met.Aci/ Hep.Enc/ BS les/ Coning </li></ul><ul><li>Apneustic – Pontine Damage </li></ul><ul><li>Cluster – Pontine/ Cerebellar damage </li></ul><ul><li>Ataxic (Biot’s) – Medullary Lesion </li></ul>
  12. 12. NEUROLOGIC EXAMINATION <ul><li>4.Fields – By Menace Reflex </li></ul><ul><li>5.Fundii –Papilledema - >12 hrs of ↑ ICT </li></ul><ul><li>Subhyloid H’ge – Asst’d č SAH </li></ul><ul><li>6.Corneal Reflex – Aff: CrV / Eff: CrVII </li></ul><ul><li>7.Gag Reflex – Absent in BS Les / Deep coma </li></ul><ul><li>11.Sensory Response – Lateralizing Sensory Loss </li></ul><ul><li>12.Deep T.Reflex – Helps in Lateralizing </li></ul><ul><li>13.Plantar Reflex -- Helps in Lateralizing </li></ul><ul><li>-- ↑ ↑ Structural / Metabolic </li></ul>
  13. 13. <ul><li>Symmetrical Reacting pupils – intact midbrain </li></ul><ul><li>Normal pupils + Absent Dolls – Metabolic / Sedatives </li></ul><ul><li>Fixed Mid position pupil – Focal Midbrain Lesion </li></ul><ul><li>Pinpoint Reactive – Pontine Damage / Opiate / OPC / Hydrocephalus / Thalamic Hemorrhage </li></ul><ul><li>Unil / Dil / Fixed – Uncal Herniation - same/opposite </li></ul><ul><li>Bil / Dil / Fixed – Central Herniation / Hypoxia / Atropine or Barbiturate Poisoning / Mydriatics </li></ul><ul><li>Eccentric oval - Early midbrain / III n Compression </li></ul><ul><li>Unil / Small (Horner) – Large Cerebral Hemorrhage Affecting Thalamus </li></ul>NEU.EXAM- 8.PUPILS.
  14. 14. <ul><li>Frontal Eye fields drive horiz. Gaze to opp.side </li></ul><ul><li>Pontine Gaze Centres drive gaze to same side </li></ul><ul><li>Midbrain tegmentum & Lower diencephalon mediates vertical gaze movements </li></ul><ul><li>Oculocephalic & Oculovestibular Reflexes act via semicircular canals / CrVIII / Vestibular and 3,4&6 th N Nuclei -- in eliciting gaze movements in comatose patients </li></ul><ul><li>Normal gaze indicate Intact Cr III – VIII (MB & PONS) </li></ul>NEU.EXAM- 9.Ocular Movements.
  15. 15. <ul><li>(A) POSITION OF THE EYES AT REST : </li></ul><ul><li>Gaze away from Hemi paresis – Contra lateral Hemispherical lesion </li></ul><ul><li>Gaze towards Hemi paresis – Contra lateral Pontine Lesion / Contra lateral Seizure Activity </li></ul><ul><li>Forced down gaze – Mid Brain Tectal / Thalamic Lesion </li></ul><ul><li>Slow roving gaze – Bihemisperical Lesion </li></ul><ul><li>Ocular bob (Slow upward Brisk Downward & Loss of Horizontal eye movements) – Bil. Pontine gaze centre dysfunction </li></ul><ul><li>Ocular Dip ( Slow Arrhythmic Downward And fast Upward eye movement with normal Dolls) – Diffuse cortical Axonal Damage </li></ul><ul><li>Saccadic (Fast) movements in Coma – Psychological </li></ul><ul><li>Horizontal divergent eyes – Drowsiness </li></ul><ul><li>Bilateral Abducted eyes – 3 rd N Dysfunction </li></ul><ul><li>Bilateral Adducted eyes – 6 th N Dysfunction (ICP) </li></ul>NEU.EXAM- 9.Ocular Movements.
  16. 16. <ul><li>(B)OCULOCEPHALIC (DOLLS) REFLEX : </li></ul><ul><li>Turn the head briskly side to side – Conjugate opposite eye movements are normal (Could not be elicited in normal persons due to supranuclear control) </li></ul><ul><li>Normal reflex in coma indicates bihemispherical / metabolic abnormality </li></ul><ul><li>Absent dolls due to (upper) brainstem lesion </li></ul>NEU.EXAM- 9.Ocular Movements.
  17. 17. <ul><li>(C) OCULOVESTIBULAR (CALORIC) REFLEX : </li></ul><ul><li>Flex the Head 30 ° -- Lavage the ear with cold ( 30 °C) water -30 ml – Observe for 30 sec – Opp. Side Nystagmus is normal response (COWS) – Tonic Eye deviation to same side </li></ul><ul><li>No Nystagmus but normal tonic phase – Bihemispherical </li></ul><ul><li>Absent Response – Deep Coma / BS dysfunction </li></ul><ul><li>Asymmetric Response – BS lesion </li></ul><ul><li>Conjugate gaze paresis -- Hemispherical / Pontine </li></ul>NEU.EXAM- 9.Ocular Movements.
  18. 18. NEU.EXAM–MOTOR RESPONSES <ul><li>Best indicator for the severity of coma </li></ul><ul><li>Observe Spontaneous movements for symmetry and purpose </li></ul><ul><li>Check tone for symmetry / Bil LL ↑ tone favors Herniation. </li></ul><ul><li>Induce increasing stimuli & observe symmetry </li></ul><ul><li>1. Verbal command -(open eyes, Show 2 fingers) </li></ul><ul><li>2.Sternal rub / pressure- (Purposeful / Gross localizing responses) </li></ul>
  19. 19. <ul><li>3.Nailbed Pressure : </li></ul><ul><li>a) Withdrawl – Motor cortex </li></ul><ul><li>b) Decortication (Flexion of the Elbow & wrist with supination of the arm)– Deep Hemisphere / Upper midbrain level inv of pyramidal tract </li></ul><ul><li>c) Decerebration (Extension of Elbows Wrist & Pronation) – Pons / Upper medullary lesion </li></ul>NEU.EXAM–MOTOR RESPONSES
  20. 20. DIAGNOSTIC TESTING <ul><li>1. Head CT (or MRI) Scan : </li></ul><ul><li>Great boon for the Diagnosis of structural lesions. </li></ul><ul><li>Mostly CT is enough & is Quick for the Patient & Doctor. </li></ul><ul><li>All types of ICH, Tumor & Hydrocephalus. </li></ul><ul><li>Bihemispherical Infarcts, BS lesion, DAI, Meningitis, Encephalitis, isodense SDH & CVT may be missed by CT Scan. </li></ul><ul><li>Contrast when required / Bone window - Trauma </li></ul><ul><li>2. Lumbar Puncture : </li></ul><ul><li>Exclude ICT / Mass effect by CT Scan Before LP </li></ul><ul><li>To Diagnose Meningitis /Encephalitis / SAH </li></ul><ul><li>Do not postpone Treatment for Men’s if LP is delayed </li></ul>
  21. 21. <ul><li>3. EEG: </li></ul><ul><li>Progressively increasing background slowing corresponds to the level of consciousness. </li></ul><ul><li>Triphasic waves in hepatic (other) Encephalopathies. </li></ul><ul><li>Asymmetric slowing in hemispherical lesion. </li></ul><ul><li>Alpha coma : Alpha waves all over – pontine / Diff.Cort </li></ul><ul><li>Excessive Beta waves in Sedative Intoxication. </li></ul><ul><li>Electrical Status in Non-Convulsive SE. </li></ul><ul><li>Normal Alpha Activity seen in Locked in syndrome & Hysteria. </li></ul>DIAGNOSTIC TESTING
  22. 22. EMERGENCY TREATMENT FOR COMA <ul><li>1. ICSOL: Surgical intervention </li></ul><ul><li>2. INCREASED ICP (For buying time): </li></ul><ul><li>a. Head Elevation </li></ul><ul><li>b. Intubation / Hyperventilation </li></ul><ul><li>c. Sedation if Agitated (midazolam) </li></ul><ul><li>d. 20% Mannitol 1gm/kg </li></ul><ul><li>e. Dexamethasone 10mg IV Q6H </li></ul><ul><li>3. ENCEPHALITIS (HSE): Acyclovir 10mg/kg IV Q8H </li></ul><ul><li>4. MENINGITIS : Ceftriaxone +Ampicillin </li></ul>
  23. 23. CAUSES OF STUPOR AND COMA <ul><li>1. STRUCTURAL </li></ul><ul><li>a)Trauma </li></ul><ul><li>i.ICH </li></ul><ul><li>ii.Diff Axon Injury </li></ul><ul><li>iii.Concussion </li></ul><ul><li>b)CVA </li></ul><ul><li>i.ICH / SAH </li></ul><ul><li>ii.Hemisp / BS Inf </li></ul><ul><li>iii.CVT </li></ul><ul><li>iv.HTN’ve Encep’thy </li></ul><ul><li>c)Infection </li></ul><ul><li>i.Meningitis </li></ul><ul><li>ii.Encephalitis </li></ul><ul><li>iii.Abscess </li></ul><ul><li>d)Inflammatory </li></ul><ul><li>i.Autoimmune Vasculitis </li></ul><ul><li>ii.Demyelination </li></ul><ul><li>e)Neoplasm </li></ul><ul><li>f)Hydrocephalus </li></ul><ul><li>2. TOXIC / METABOLIC </li></ul><ul><li>a)Global Hypoxia / Ischemia </li></ul><ul><li>b)Elec’te / Acid-Base Disorders </li></ul><ul><li>i.pH Disturbances </li></ul><ul><li>ii. Hyper/Hypo Natremia </li></ul><ul><li>iii. Hyper/Hypo Glycemia </li></ul><ul><li>iv. Hyper/Hypo Calcemia </li></ul><ul><li>c)Drug intoxic’n / Withdrawl </li></ul><ul><li>d)Temp’re (Hyper/Hypo thermia) </li></ul><ul><li>e)Organ System Dysfunction </li></ul><ul><li>i.Liver </li></ul><ul><li>ii.Kidney </li></ul><ul><li>iii.Thyroid </li></ul><ul><li>iv.Adrenal </li></ul><ul><li>v.Cardiac /Respiratory </li></ul><ul><li>f)Seizures and Post-ictal states </li></ul><ul><li>g)Thiamine / B12 Deficiency </li></ul><ul><li>3. PSYCOGENIC COMA </li></ul>
  24. 24. CEREBRO VASCULAR ACCIDENT <ul><li>10% of coma are due to CVA </li></ul><ul><li>Variable depth of coma with Hemiplegia </li></ul><ul><li>Large infarct / ICH -Facial / Limb Weakness </li></ul><ul><li>IVH -Decerebration / Meningismus </li></ul><ul><li>Brain Stem Infarct - BS Signs </li></ul><ul><li>VBI - Loss of Bl.Supply to RAS - Drop attack </li></ul><ul><li>SAH - Th’rclap HA , Mening’s , Focal deficits </li></ul><ul><li>HT.E - Blindness,Fits,Paps,Retino/Nephro’y </li></ul><ul><li>CVT-Fits,HA,ICT,Mening’s,Focal Deficits </li></ul><ul><li>Small vessel occl’n-SLE,SBE,DIC,TTP </li></ul>
  25. 25. Ischemic Gliosis of Pons
  26. 26. SLE
  27. 27. Pontine Infarct
  28. 28. Intra Cerebral Hemorrhage
  29. 29. ANEURYSM & SAH <ul><li>10 / 1,00,000 PER YEAR </li></ul><ul><li>Frequently in females </li></ul><ul><li>Age, HTN, Smoking, Alcohol –risk </li></ul><ul><li>70% gets Warning leaks </li></ul><ul><li>45% Manifest as COMA at the onset </li></ul><ul><li>Suspicion, CT & LP are Diagnostic methods </li></ul><ul><li>MRA, CT Angio & DSA for confirmation </li></ul><ul><li>Close monitor’g, rest, sedate, Vol.expaners, AED, Avoid Vasospasm, Anti HTN, & Dulcolax </li></ul><ul><li>Plan Surgery at the earliest </li></ul>
  30. 30. Aneurysms
  31. 31. <ul><li>13% of coma are due to trauma </li></ul><ul><li>History & Evidences of external Injury </li></ul><ul><li>Concussion – Immediate / Late Coma </li></ul><ul><li>Contusion / Laceration – Foc.def / Seiz’s </li></ul><ul><li>EDH (MMA H’ge) - Lucid Interval </li></ul><ul><li>SDH – Delayed Symptoms </li></ul><ul><li>Monitor T,P,BP,ICP,CT, MRI,C.Spine for all Trauma. </li></ul>TRAUMA
  32. 32. Contusion / Concussion / DAI / SAH
  33. 33. <ul><li>Common Cause of Coma </li></ul><ul><li>Flushed face, Conj.inj., Bounding pulse, Dil’d pp, </li></ul><ul><li>Alcohol from Breath, Stomach & Blood </li></ul><ul><li>ICH, Trauma, SDH, Wernicke’s Encp’thy </li></ul><ul><li>Urgent CT, LFT, Coag’ln profile </li></ul><ul><li>Inj.B1 & 50% Dextrose if hypoglycemic </li></ul><ul><li>AED if H/O seizures </li></ul>ALCOHOL INTOXICATION
  34. 34. <ul><li>Tongue bite, Froath, Bloody sputum, Injury </li></ul><ul><li>Etiology of convulsion may be different </li></ul><ul><li>Confusion & Irritability </li></ul><ul><li>Brief stupor and profound sleep </li></ul><ul><li>To rule out Non-Convulsive Status </li></ul>Post ictal state DIABETES <ul><li>Hypo is worse so give IV dextrose </li></ul><ul><li>Dec DTR, T, BP, Hyd’n, / Inc P, R </li></ul><ul><li>Smell of Acetone </li></ul>
  35. 35. <ul><li>Suicidal/ Homicidal/ Accidental </li></ul><ul><li>Drugs and Toxins </li></ul><ul><li>History / Physical findings </li></ul><ul><li>Lavage/ Symptomatic/ Antidote/ Tt Compl </li></ul><ul><li>No Lateralizing signs </li></ul><ul><li>Depth of coma Acc to Strength & Amount </li></ul>Poisoning Meningitis <ul><li>HA, Fever, LOC, Meningismus (not in age extremes & Imm. supp), ICP </li></ul><ul><li>ENT infection, SBE, </li></ul><ul><li>Rash in mening.meng’s </li></ul><ul><li>Do CT before LP </li></ul>
  36. 36. ENCEPHALITIS <ul><li>Present with Fever, Meningismus, Altered sensorium, seizures and focal Deficits. </li></ul><ul><li>Usually the Seizures are difficult to control </li></ul><ul><li>EEG& CSF are better diagnostic tools than Imaging </li></ul><ul><li>HSE affects FT regions asymmetrically present with focal seizures </li></ul><ul><li>EEG may show PLEDs, Focal epileptic activity or slowing </li></ul><ul><li>MRI shows signal alterations in inferior FT regions asymmetrically </li></ul><ul><li>IV Acyclovir is the Treatment of choice with full dose AED </li></ul>
  37. 37. Herpes Simplex Encephalitis
  38. 38. PSEUDOCOMA <ul><li>1. PSYCHOGENIC COMA </li></ul><ul><li>Negativistic Behavior (Resists opening eye) </li></ul><ul><li>Avoidance Behavior (Hand avoids face on dropping) </li></ul><ul><li>Intact Saccades / Normal Caloric response </li></ul><ul><li>Recovery on very painful stimuli </li></ul><ul><li>2. LOCKED IN SYNDROME </li></ul><ul><li>Complete paralysis except for vertical eye movements </li></ul><ul><li>Pt usually alert and can communicate thru’ EOM </li></ul><ul><li>Due to bilateral Pontine Damage (Infarct) </li></ul><ul><li>3. AKINETIC MUTISM (Motionless, Mindless Wakefulness) </li></ul><ul><li>Extreme psychomotor retardation- Appears awake </li></ul><ul><li>Show Delayed Limited responses </li></ul><ul><li>Due to Extensive Thalamic / Frontal Damage </li></ul>
  39. 39. VEGETATIVE STATE <ul><li>Loss of Awareness of self and surroundings. </li></ul><ul><li>Normal sleep wake cycles & BS reflexes. </li></ul><ul><li>Normal metabolic and circulatory functions. </li></ul><ul><li>Normal eye opening / closure & Swallowing. </li></ul><ul><li>Eye movements & Sensory Localization – Poor. </li></ul><ul><li>Doesn’t obey requ’s / No comprehensible words. </li></ul><ul><li>Preserved Hypothalamic & Autonomic fns. </li></ul><ul><li>Above findings lasting > 1 month – PVS. </li></ul><ul><li>CVA, SAH, Trauma, Toxin, Injury, Infn, Arrest etc., </li></ul><ul><li>Low amplitude irregular Delta in EEG. </li></ul><ul><li>Cortical necrosis, multi-infarcts, Diffuse neuronal loss and gliosis of neocortex, hippocampus thalamus & purkinje cells – BS relatively intact. </li></ul>
  40. 40. GENERAL CARE FOR COMATOSE PTS <ul><li>Protect airway / Adeq. Vent’n & O2 / NPO </li></ul><ul><li>Good Hydration – Prefer isotonic Saline </li></ul><ul><li>Nasogatric adeq. calorie feed with smaller tube </li></ul><ul><li>Prevent Bedsore – Q2H Position / Water bed </li></ul><ul><li>Protect Eyes by keeping closed / Lubricants </li></ul><ul><li>Ranitin to prevent Stress ulcer / Stool softener </li></ul><ul><li>Aseptic Catherization / Intermittent catheteris’n </li></ul><ul><li>Passive Limb Exercises to prevent Contractures </li></ul><ul><li>Calf exe / Stocking / Heparin to avoid DVT </li></ul>
  41. 41. BRAIN DEATH <ul><li>State of cessation of cerebral activity with normal Heart function, Respiration being maintained by Ventilators. </li></ul><ul><li>Brain death is the Death of the Individual </li></ul><ul><li>Three Essential elements for Dx </li></ul><ul><li>1. Widespread Cortical Destruction (Unresponsive to all stimuli) </li></ul><ul><li>2.Global BS Damage (Loss of all BS reflexes) </li></ul><ul><li>3.Lower BS destruction – Complete Apnea </li></ul><ul><li>Exclude Drug induced / Hypothermic CNS Depression </li></ul>
  42. 42. THANK YOU

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