Coma <ul><li>A state of unarousable psychologic unresponsive-ness in which the subjects lies with  eyes closed </li></ul><...
<ul><li>Hypersomnia </li></ul><ul><ul><li>excessive drowsiness and excessive sleep </li></ul></ul><ul><ul><li>narcolepsy, ...
<ul><li>Locked-in syndrome </li></ul><ul><ul><li>total paralysis of all somatic musculature </li></ul></ul><ul><ul><li>pre...
Three categories of Coma <ul><li>Diffuse brain dysfunction </li></ul><ul><ul><li>matabolic encephalopathy </li></ul></ul><...
Systemic evaluation of Coma <ul><li>Is there systemic illness causing brain failure? </li></ul><ul><li>Is there evidence o...
Neurological examination in Coma <ul><li>Response to external stimulation </li></ul><ul><li>Motor response </li></ul><ul><...
Response to external stimulation <ul><li>In order of  verbal command ,  shouting ,  shaking , and  noxious stimulation </l...
Motor responses <ul><li>Absence of any motor response </li></ul><ul><ul><li>severe brain stem damage </li></ul></ul><ul><u...
Pupillary responses <ul><li>Small, reactive pupils </li></ul><ul><ul><li>metabolic </li></ul></ul><ul><ul><li>IICP with hy...
Pupillary responses <ul><li>Midposition and fixed pupils </li></ul><ul><ul><li>midbrain dysfunction </li></ul></ul><ul><ul...
Eye movements <ul><li>Spontaneous roving, horizontal and conjugate eye movements </li></ul><ul><ul><li>intact brain stem <...
Eye movements <ul><li>Doll’s eyes reflex </li></ul><ul><ul><li>intact brainstem function with depressed cortical influence...
Pattern of breathing <ul><li>Cheyne-Stokes respiration </li></ul><ul><li>Central neurogenic hyperventilation </li></ul><ul...
Cheyne-Stokes respiration <ul><li>Periodic breathing, crescendo-decrescendo </li></ul><ul><li>The result of the loss of fr...
Central neurogenic hyperventilation <ul><li>Sustained, rapid, deep hyperpnea </li></ul><ul><li>Not  secondary to hypoxemia...
Apneustic breathing <ul><li>Prolonged inspiratory gasp </li></ul><ul><li>Discrete lesions of the mid-to-lower pons </li></...
Ataxic and irregular periodic breathing <ul><li>Completely irregular pattern </li></ul><ul><li>Slow and progressed to apne...
Differential diagnosis of Coma <ul><li>Metabolic and toxic causes </li></ul><ul><ul><li>presence of pupillary light reflex...
Differential diagnosis of Coma <ul><li>Supratentorial mass lesions </li></ul><ul><ul><li>focal neurologic sings </li></ul>...
Diagnostic procedures <ul><li>Metabolic or toxic causes </li></ul><ul><ul><li>blood, urine, gastric aspirates testing </li...
Treatment of Coma <ul><li>Immediate treatment, even when the diagnosis is uncertain, to prevent further brain damage </li>...
Treatment of Coma <ul><li>Glucose  (50 mL of 50% glucose) </li></ul><ul><li>Thiame  (100 mg, with the glucose) </li></ul><...
Prognosis:  Hypoxic-ischemic encephalopathy <ul><li>1st day:  absence of pupillary responses predicts poor outcome </li></...
Persistent Vegetative State (PVS) <ul><li>A form of eyes-open permanent unconsciousness. </li></ul><ul><li>Periods of wake...
Persistent Vegetative State (PVS) <ul><li>No voluntary action or behavior. Only primitive reflexes and vegetative function...
Neurological criteria for Death <ul><li>The Uniform Determination of Death Acts: </li></ul><ul><ul><li>irreversible cessat...
Diagnosis of Death by neurologic criteria <ul><li>A  clinical  diagnosis, with preconditions and confirmatory tests </li><...
腦死判定程序  76.9.17. 衛生署醫字第 688301 號公告 <ul><li>僅適用於人體器官移植之特定範圍 </li></ul><ul><li>判定前之先決條件 </li></ul><ul><ul><li>深度昏迷,不能自行呼吸 </...
腦死判定程序  -  臨床檢視 <ul><li>確認無下列徵象 </li></ul><ul><ul><li>自發性呼吸 </li></ul></ul><ul><ul><li>異常姿勢,如去皮質或去大腦之姿勢 </li></ul></ul><ul...
腦死判定程序  -  腦幹功能測試 <ul><li>確認腦幹反射消失 </li></ul><ul><ul><li>頭、眼反射 </li></ul></ul><ul><ul><li>瞳孔對光反射 </li></ul></ul><ul><ul><l...
腦死判定程序  -  測試無自行呼吸  (Apnea test) <ul><li>由人工呼吸器供應 100% 氧氣 10 分鐘 </li></ul><ul><li>給予 95% 氧氣加 5% 二氧化碳 5 分鐘使動脈血中 PaCO 2 達到 4...
腦死判定程序  -  第二次測試 <ul><li>第一次測試完畢後至少四小時後為之 </li></ul><ul><li>腦死判定,經第二次測試,如病人仍完全符合無腦幹反射與不能自行呼吸之條件,即可判定病人腦死 </li></ul>
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Coma A state of unarousable psychologic unresponsive-ness in ...

  1. 1. Coma <ul><li>A state of unarousable psychologic unresponsive-ness in which the subjects lies with eyes closed </li></ul><ul><li>Coma vs. Consciousness </li></ul><ul><li>Consciousness: wakefulness and responsiveness </li></ul><ul><li>The severity of coma is measured by comparing the intensity of an external stimulus and the complexity and purposefulness of the response </li></ul>
  2. 2. <ul><li>Hypersomnia </li></ul><ul><ul><li>excessive drowsiness and excessive sleep </li></ul></ul><ul><ul><li>narcolepsy, hypothalamic disorders, drugs </li></ul></ul><ul><li>Akinetic mutism </li></ul><ul><ul><li>silent, alert, and awake appearance </li></ul></ul><ul><ul><li>regular sleep-wake cycles </li></ul></ul><ul><ul><li>no evidence of response to the environment, mental activities, or spontaneous movements </li></ul></ul>
  3. 3. <ul><li>Locked-in syndrome </li></ul><ul><ul><li>total paralysis of all somatic musculature </li></ul></ul><ul><ul><li>preserved consciousness and most sensory modalities </li></ul></ul><ul><ul><li>preserved vertical eye movements </li></ul></ul><ul><ul><li>ventral pontine infarct </li></ul></ul><ul><li>Persistent vegetative state </li></ul><ul><ul><li>preserved brainstem function, including breathing </li></ul></ul><ul><ul><li>spontaneous eye opening and regular sleep-wake cycles </li></ul></ul><ul><ul><li>no recognizable cognitive function </li></ul></ul>
  4. 4. Three categories of Coma <ul><li>Diffuse brain dysfunction </li></ul><ul><ul><li>matabolic encephalopathy </li></ul></ul><ul><ul><li>drug intoxication </li></ul></ul><ul><li>Primary brain stem disorders </li></ul><ul><ul><li>brainstem stroke </li></ul></ul><ul><ul><li>brainstem neoplasm, absecess </li></ul></ul><ul><li>Supratentorial mass lesions </li></ul><ul><ul><li>causing secondary brain stem compression </li></ul></ul>
  5. 5. Systemic evaluation of Coma <ul><li>Is there systemic illness causing brain failure? </li></ul><ul><li>Is there evidence of diffuse or focal brain injury? </li></ul><ul><li>Is the patient improving or deteriorating? </li></ul>
  6. 6. Neurological examination in Coma <ul><li>Response to external stimulation </li></ul><ul><li>Motor response </li></ul><ul><li>Size and reactivity of pupils </li></ul><ul><li>Eye movements and ocular reflexes </li></ul><ul><li>Pattern of breathing </li></ul>
  7. 7. Response to external stimulation <ul><li>In order of verbal command , shouting , shaking , and noxious stimulation </li></ul><ul><li>Localizing pain </li></ul><ul><ul><li>preserved brain stem function and intact connections to the appropriate cerebral hemisphere </li></ul></ul><ul><li>Eye opening </li></ul><ul><ul><li>preserved function of RAS </li></ul></ul>
  8. 8. Motor responses <ul><li>Absence of any motor response </li></ul><ul><ul><li>severe brain stem damage </li></ul></ul><ul><ul><li>severe sedative drug ingestion </li></ul></ul><ul><li>Decorticate, flexor posturing of the arms </li></ul><ul><ul><li>bilateral cerebral hemisphere damage </li></ul></ul><ul><ul><li>toxic/metabolic encephalopathy </li></ul></ul><ul><li>Decerebrate, extensor posturing of the arms </li></ul><ul><ul><li>destructive lesions of the midbrain and upper pons </li></ul></ul><ul><ul><li>hepatic and anoxic-ischemic encephalopathy </li></ul></ul>
  9. 9. Pupillary responses <ul><li>Small, reactive pupils </li></ul><ul><ul><li>metabolic </li></ul></ul><ul><ul><li>IICP with hypothalamic dysfunction </li></ul></ul><ul><li>Very small pupils (pinpoint) </li></ul><ul><ul><li>pontine lesion </li></ul></ul><ul><ul><li>narcotic (opioids) overdose </li></ul></ul><ul><li>Bilateral dilated fixed pupils </li></ul><ul><ul><li>seizure, anoxic encephalopathy </li></ul></ul><ul><ul><li>exogenous catecholamimes </li></ul></ul>
  10. 10. Pupillary responses <ul><li>Midposition and fixed pupils </li></ul><ul><ul><li>midbrain dysfunction </li></ul></ul><ul><ul><li>brain death </li></ul></ul><ul><li>Unilateral dilated pupil </li></ul><ul><ul><li>damage to IIIrd nerve from trnastentorial herniation </li></ul></ul>
  11. 11. Eye movements <ul><li>Spontaneous roving, horizontal and conjugate eye movements </li></ul><ul><ul><li>intact brain stem </li></ul></ul><ul><ul><li>diffuse or metabolic cortical dysfunction </li></ul></ul><ul><li>Conjugate lateral deviation </li></ul><ul><ul><li>massive hemispheric lesion (eyes toward lesion) </li></ul></ul><ul><ul><li>pontine lesion (eyes away from lesion) </li></ul></ul>
  12. 12. Eye movements <ul><li>Doll’s eyes reflex </li></ul><ul><ul><li>intact brainstem function with depressed cortical influences </li></ul></ul><ul><ul><li>normal sleep, coma, persistent vegetative state </li></ul></ul><ul><li>Ice water caloric test </li></ul><ul><ul><li>eyes toward the side of cold water </li></ul></ul><ul><ul><li>absence in brainstem lesion, inner ear disease, deep drug coma, and anticonvulsants overdose </li></ul></ul>
  13. 13. Pattern of breathing <ul><li>Cheyne-Stokes respiration </li></ul><ul><li>Central neurogenic hyperventilation </li></ul><ul><li>Apneustic breathing </li></ul><ul><li>Irregular periodic breathing </li></ul><ul><li>Ataxic breathing </li></ul><ul><li>Yawning </li></ul>
  14. 14. Cheyne-Stokes respiration <ul><li>Periodic breathing, crescendo-decrescendo </li></ul><ul><li>The result of the loss of frontal lobe controls </li></ul><ul><li>Blood PCO2 drives brain stem respiratory center </li></ul><ul><li>Posthyperventilation apnea </li></ul><ul><li>Causes </li></ul><ul><ul><li>Frontal lobe damage, unilateral or bilateral </li></ul></ul><ul><ul><li>Secondary to cardiac or respiratory failure </li></ul></ul>
  15. 15. Central neurogenic hyperventilation <ul><li>Sustained, rapid, deep hyperpnea </li></ul><ul><li>Not secondary to hypoxemia and acidemia </li></ul><ul><li>Causes </li></ul><ul><ul><li>Upper brain stem lesion </li></ul></ul><ul><ul><li>Metabolic disorders, especially the early stages of hepatic coma </li></ul></ul>
  16. 16. Apneustic breathing <ul><li>Prolonged inspiratory gasp </li></ul><ul><li>Discrete lesions of the mid-to-lower pons </li></ul><ul><li>Need early intubation and ventilation </li></ul><ul><li>Causes </li></ul><ul><ul><li>pontine infarct </li></ul></ul><ul><ul><li>hypoglycemia, anoxia, or severe meningitis </li></ul></ul>
  17. 17. Ataxic and irregular periodic breathing <ul><li>Completely irregular pattern </li></ul><ul><li>Slow and progressed to apnea </li></ul><ul><li>Respiratory center - dorsomedial medulla </li></ul><ul><li>Terminal states </li></ul><ul><li>Causes </li></ul><ul><ul><li>posterior fossa lesions </li></ul></ul><ul><ul><li>medullary damage </li></ul></ul><ul><ul><li>overdoses of opiate and sedatives </li></ul></ul>
  18. 18. Differential diagnosis of Coma <ul><li>Metabolic and toxic causes </li></ul><ul><ul><li>presence of pupillary light reflex </li></ul></ul><ul><ul><li>confusion and stupor precedes </li></ul></ul><ul><ul><li>symmetric motor signs </li></ul></ul><ul><ul><li>asterixis, myoclonus, tremor, seizures (generalized) </li></ul></ul><ul><ul><li>central hyperventilation </li></ul></ul>
  19. 19. Differential diagnosis of Coma <ul><li>Supratentorial mass lesions </li></ul><ul><ul><li>focal neurologic sings </li></ul></ul><ul><ul><li>progresses in a rostral-caudal fasion </li></ul></ul><ul><li>Subtentorial masses or destructive lesions </li></ul><ul><ul><li>sudden onset of coma </li></ul></ul><ul><ul><li>history of brain stem dysfunction (the 6 D’s) </li></ul></ul><ul><ul><li>abnormal eye movements </li></ul></ul><ul><ul><li>cranial palsies </li></ul></ul><ul><ul><li>irregular respiration </li></ul></ul>
  20. 20. Diagnostic procedures <ul><li>Metabolic or toxic causes </li></ul><ul><ul><li>blood, urine, gastric aspirates testing </li></ul></ul><ul><ul><li>EEG </li></ul></ul><ul><li>Intracranial mass lesions, head injury </li></ul><ul><ul><li>CT </li></ul></ul><ul><li>Acute subarachnoid or intracerebral hemorrhage </li></ul><ul><ul><li>CT </li></ul></ul><ul><ul><li>lumbar punctures </li></ul></ul><ul><li>Meningitis or encephalitis </li></ul><ul><ul><li>lumbar punctures </li></ul></ul>
  21. 21. Treatment of Coma <ul><li>Immediate treatment, even when the diagnosis is uncertain, to prevent further brain damage </li></ul><ul><li>Oxygenation and airway protection </li></ul><ul><ul><li>ET tube </li></ul></ul><ul><ul><li>ventilation </li></ul></ul><ul><li>Blood pressures maintain </li></ul><ul><ul><li>volume replacement with isotonic solutions </li></ul></ul><ul><ul><li>hemodynamic monitoring </li></ul></ul><ul><ul><li>inotropic and vasopressor drugs </li></ul></ul>
  22. 22. Treatment of Coma <ul><li>Glucose (50 mL of 50% glucose) </li></ul><ul><li>Thiame (100 mg, with the glucose) </li></ul><ul><li>Seizures stop </li></ul><ul><li>Intracranial hypertension lower </li></ul><ul><li>Systemic infections control </li></ul><ul><li>Acid-base and electrolytes imbalances correct </li></ul><ul><li>Hyperthermia treat </li></ul>
  23. 23. Prognosis: Hypoxic-ischemic encephalopathy <ul><li>1st day: absence of pupillary responses predicts poor outcome </li></ul><ul><li>2nd day: no patients lack corneal reflex regained consciousness </li></ul><ul><li>After 3rd day: lack or purposeful motor responses predict poor outcome </li></ul>
  24. 24. Persistent Vegetative State (PVS) <ul><li>A form of eyes-open permanent unconsciousness. </li></ul><ul><li>Periods of wakefulness and physiologic sleep/wake cycles. </li></ul><ul><li>Unaware of self or environment. </li></ul>
  25. 25. Persistent Vegetative State (PVS) <ul><li>No voluntary action or behavior. Only primitive reflexes and vegetative functions. </li></ul><ul><li>Careful and extended clinical observation, supported by laboratory studies. </li></ul><ul><li>In cases of hypoxic-ischemic encephalopathy, observation period of one to three months. </li></ul><ul><li>Prolonged survival. </li></ul><ul><li>No pain or suffering. </li></ul>
  26. 26. Neurological criteria for Death <ul><li>The Uniform Determination of Death Acts: </li></ul><ul><ul><li>irreversible cessation of circulatory and respiratory functions, or </li></ul></ul><ul><ul><li>irreversible cessation of all functions of the entire brain, including the brain stem </li></ul></ul><ul><li>The determination of death must be made in accordance with accepted medical standards </li></ul>
  27. 27. Diagnosis of Death by neurologic criteria <ul><li>A clinical diagnosis, with preconditions and confirmatory tests </li></ul><ul><li>The core of the clinical diagnosis is to establish unresponsiveness and brain stem areflexia </li></ul><ul><li>The preconditions </li></ul><ul><ul><li>the cause of coma be known </li></ul></ul><ul><ul><li>the cause be adequate to explain the coma </li></ul></ul>
  28. 28. 腦死判定程序 76.9.17. 衛生署醫字第 688301 號公告 <ul><li>僅適用於人體器官移植之特定範圍 </li></ul><ul><li>判定前之先決條件 </li></ul><ul><ul><li>深度昏迷,不能自行呼吸 </li></ul></ul><ul><ul><li>導致昏迷的原因已確定 </li></ul></ul><ul><ul><li>無法復原之腦部結構損壞 </li></ul></ul><ul><li>排除可逆性昏迷 </li></ul><ul><ul><li>如新陳代謝障礙、藥物中毒與低體溫導致之昏迷 </li></ul></ul><ul><ul><li>罹病原因不明,即應排除 </li></ul></ul><ul><li>使用人工呼吸器,至少觀察 12 小時 </li></ul>
  29. 29. 腦死判定程序 - 臨床檢視 <ul><li>確認無下列徵象 </li></ul><ul><ul><li>自發性呼吸 </li></ul></ul><ul><ul><li>異常姿勢,如去皮質或去大腦之姿勢 </li></ul></ul><ul><ul><li>癲癇性抽搐 </li></ul></ul>
  30. 30. 腦死判定程序 - 腦幹功能測試 <ul><li>確認腦幹反射消失 </li></ul><ul><ul><li>頭、眼反射 </li></ul></ul><ul><ul><li>瞳孔對光反射 </li></ul></ul><ul><ul><li>眼角膜反射 </li></ul></ul><ul><ul><li>前庭、動眼反射 </li></ul></ul><ul><ul><li>對身體任何部位之疼痛刺激、在顱神經分佈區範圍內,不能引起運動反應 </li></ul></ul><ul><ul><li>以導管在氣管抽痰時,不能引起作嘔咳嗽之反射 </li></ul></ul>
  31. 31. 腦死判定程序 - 測試無自行呼吸 (Apnea test) <ul><li>由人工呼吸器供應 100% 氧氣 10 分鐘 </li></ul><ul><li>給予 95% 氧氣加 5% 二氧化碳 5 分鐘使動脈血中 PaCO 2 達到 40 mmHg 以上 </li></ul><ul><li>取除人工呼吸器,並由氣管內管供應 100% 氧氣,每分鐘 6 公升 </li></ul><ul><li>觀察 10 分鐘,並測最後血中 PaCO 2 濃度 </li></ul><ul><li>確認病人無法自行呼吸 </li></ul>
  32. 32. 腦死判定程序 - 第二次測試 <ul><li>第一次測試完畢後至少四小時後為之 </li></ul><ul><li>腦死判定,經第二次測試,如病人仍完全符合無腦幹反射與不能自行呼吸之條件,即可判定病人腦死 </li></ul>

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