Coma in non neurological intensive
care units
Santiago ortega et al
University college of Wisconsin.
The Neurologist,Nov,...
Back ground
 Increased survival among medical and
surgical ICU.
 Increasing spectrum of illness secondary to
critical il...
Clinical history
 Physical examination
Degree of sedation
Neurologic examination
Herniation syndromes
Coma scales
Essential clinical history in patients
with loss of consciousness
History
Time course-abrupt
gradual
fluctuating
Preceding...
Vital signs interpretation in
comatose patients
Vital signs
Fever
Hypothermia
Hypertension
Potential illnesses
Infection, ...
Vital signs interpretation in
comatose patients
Hypotension
Tachycardia
Bradycardia
HTN-Bradycardia
Addisons, sepsis, MI,
...
Respiratory patterns in coma
 Cheyne stroke
 Kussmaul breathing
 Agonal gasps
 Central neurogenic
hyprventilation
 Ap...
Cutaneous and mucosal exam in
comatose
 Petechiae &ecchymosis
 Hypermelanosis
 Cherry red skin
 Gray blue cyanosis
 T...
Neuro muscular blockers in ICU
succinylcholin
e 5-10min -t1/2 renal
rapacurium
12-17 60-120 - hepatic
mivacurium
12-18 2 r...
Sedatives in ICU
diazepam 50-120 Icp, cbf,
lorazepam 3-7
midazolam 7-10
morphine 4-11 Cbf,icp
fentanyl 10
thiopental 2-4 C...
Evaluation of comatose
 Spontaneous activity, motor response, eye
position and movements, pupillary reflexes,
brainstem r...
Main opthalmologic findings in
comatose
 Vitreous sub hyaloid
haemorrages
 Papilledema,retinal
exudates&haemorrages
 Pa...
Eye movements in coma
 Conjugate horizontal roving
 Conjugate horizontal ocular
deviation
 Wrong way eyes
 Downward ,i...
Abnormal pupillary responses in
coma
Bilateral small ,reactive
b/l dilated and unreactive
b/l dilation&reactive
Unilateral...
Pupillary responses and coma
Unilateral, unreactive &
enlarged
-unilateral ptosis
-bilateral ptosis
Unilateral,small,react...
Glasgow coma scale
FOUR score scale
Eye response
4-eyelid open or opened, tracking or
blinking to command
3-eyelids open, not tracking
2-eyel...
Cerebral herniation :clinical
syndromes
Uncal herniation Hemispheric/later
al middle fossa
Ipsilateral III
compression
Dil...
Cerebral herniation clincal
syndromes
Midbrain
compression
Advanced stage
of central
herniation,
upward infra
tentorial le...
Differential diagnosis in non
neurological ICU
Metabolic coma
Structural coma
major causes of organic coma-
supra tentorial
 Unilateral
Hemorrhagic contusion
Subdural hematoma
Epidural hematoma
MCA o...
Major causes of organic coma-
infratentorial
 Brainstem
pontine bleed
basilar artery
occlusion
central pontine
myelinolys...
Medical ICU
 Metabolic encephalopathy-28.6%
 Seizures-28.1%
 Hypoxic ischemic encephalopathy-23.5%
 Stroke-22.1%
 Sep...
Primary CNS processes
 Acute stroke-1-4% in non neuro icu.
Angiographic studies
De clotting of Av shunts
Vascular line in...
Primary CNS processes
Meningitis & encephalitis-change in
mental state with fever, csf analysis and
antibiotics.
Posteri...
Conditions associated with acute hypertensive crisis &
hypertensive encephalopathy
 Toxemia of pregnancy
 Drugs-cyclospo...
Primary CNS processes
 New onset seizure-0.8-4%,focal most
common.
 Myoclonic seizures-metabolic, drugs,hypoxia.
 Non c...
Common precipitants of seizures in
ICU
 Metabolic: renal,
hepatic,
electrolyte,
Endocrine
 Hypoxia/ischemia
 Sepsis
 S...
Secondary CNS processes
Encephalopathy is the most common
neurological complication in medical
ICU.
Prolonged sedation
...
Sodium disturbances
 Hypo natremia-incidence of1%,prevalence of
2.5%.
Postoperative patients
Lethargy, confusion, coma ,s...
Calcium disturbance
Hyper calcemia- ionised calcium levels
and rate of rise.
Delirium, depression, coma.
Hypo calcemia-c...
Magnesium disturbances
Hypo magnesemia-commonly
associated with hypo calcemia.
Tremor, tetany, myoclonus and seizures.
H...
Acid base disturbances
 Severe acidemia-
<7.2,metabolic,respiratory,mixed
Increase of icp, decrease seizure thresold,
sti...
renal
 Uremic encephalopathy-BUN doubles, drowsiness,
asterexis, myoclonus
 Post dialysis disequilibrium-rapid dialysis,...
liver
Acute hepatic failure-hyper ammonemia,
hepatic encephalopathy.
Gr IV -80% mortality
pH dependent partial pressure o...
Hypoxic ischemic encephalopathy
 Hypotension, hypoxemia, asphyxia,
laryngeal edema
Severity and duration of hypoxia
Trans...
Sepsis encephalopathy
Most common (70%) in medical icu.
Highest mortality
Multi organ failure
Decreased cerebral O2 ex...
Surgical ICU
 Cholesterol embolisation-vascular catheterisation
diffuse encephalopathy, retinal hemorrhage, transient
hem...
Transplant ICU
Transplant organ/procedure related
Immunosuppressive therapy
Renal/liver transplantation
Cutaneous neuropathies ad spinal cord
infarction
Re vascularisation procedure
BP changes
H...
Cardiac/BMT
Single/multiple cerebral infarctions-
emboli, global hypo perfusion,
arrhythmias, bypass pump, supra
therapeu...
cyclosporine
Tremor and restlessness
Syndome1-confusion,cortical blindness,
visual hallucinations
Syndrome2-ataxia,cere...
Tacrolimus/muromonab
 Fine tremor, paresthesias, apraxia, aphasia,
akinetic mutism.
Cortical blindness, CIDP
 Aseptic me...
Offering prognosis
 Etiology, severity, secondary CNS damage, age.
 5-pont Glasgow outcome scale,6-point pediatric
cereb...
Anoxic coma
 Pupils, corneal reflex, motor response to
pain ,myoclonic status, SSEP, serum neuron
specific enolase.
 No ...
Brain death and organ donation
 Irreversible loss of brain function including
brainstem
 Traumatic brain injury and SAH
...
hypothermia
 To minimize secondary brain damage
 Avoid hyperthermia-excito toxicity, free radical
generation, inflammati...
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neurological illness in ICU

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neurological illness in ICU

  1. 1. Coma in non neurological intensive care units Santiago ortega et al University college of Wisconsin. The Neurologist,Nov,2009.
  2. 2. Back ground  Increased survival among medical and surgical ICU.  Increasing spectrum of illness secondary to critical illness  1/3 of icu patients,55% mortality rate  Increase length of stay and disability  Systematic approach to identify potentially reversible etiologies and prognostic factors
  3. 3. Clinical history  Physical examination Degree of sedation Neurologic examination Herniation syndromes Coma scales
  4. 4. Essential clinical history in patients with loss of consciousness History Time course-abrupt gradual fluctuating Preceding focal signs Previous episodes h/o recent illness h/o recent fall Altered behaviour Drugs Medical psychological history Alcohol drug abuse Possible causes SAH, seizure, bleeding Tumour, venous thrombosis Metabolic,subdural hematoma. Focal lesion TIA, seizure Infection, metabolic Subdural, epidural bleed Toxic, metabolic, infection Toxic-metabolic. Metabolic, psychiatric Toxic-metabolic
  5. 5. Vital signs interpretation in comatose patients Vital signs Fever Hypothermia Hypertension Potential illnesses Infection, heatstroke, thyrotoxicosis, Drugingestion(cocaine,amphetamin es,Tca,anticholinergic) Cold exposure, hypothyroidism, hypoglycemia, shock, Drugs(alcohol,barbiturates,opioids,s edatives) Pheochromocytoma, drugs (cocaine,amphetamine,phencycli dine)
  6. 6. Vital signs interpretation in comatose patients Hypotension Tachycardia Bradycardia HTN-Bradycardia Addisons, sepsis, MI, Blood loss, hypothyroidism Alcohol, amphetamines, ethylene glycol Uremic coma, myxedema coma. Kocher-cushing reflex.
  7. 7. Respiratory patterns in coma  Cheyne stroke  Kussmaul breathing  Agonal gasps  Central neurogenic hyprventilation  Apneusis  Cluster  ataxic -Bihemispheric damage, metabolic -Metabolic acidosis, post mesencephalic lesions -Bilateral lower brainstem lesions -Bihemispheric,midbrain,pons -Lateral tegmentum of lower pons -Bihemispheric or pons -Dorsomedial medulla RAS
  8. 8. Cutaneous and mucosal exam in comatose  Petechiae &ecchymosis  Hypermelanosis  Cherry red skin  Gray blue cyanosis  Telangiectasia  Ecthyma gangrenosum  Splinter hemorrages  pigmentedmacules TTP,ITP,DIC,RMSF,meningococce mia,vasculitis,endocarditis Addisons,chemotherapy,porphyria, melanoma .CO poisoning .Methemoglobinemia Chronic alcoholism,vascular malformations Pseudomonas sepsis Anemia,sepsis,leucemia,endocarditi s Tuberous sclerosis,neurofibromatosis
  9. 9. Neuro muscular blockers in ICU succinylcholin e 5-10min -t1/2 renal rapacurium 12-17 60-120 - hepatic mivacurium 12-18 2 renal atracuronium 30-40 20 renal vecuronium 20-60 60-130 renal hepatic rocuronium 30-67 80-100 renal pancuronium 120-180 110-140 renal hepatic tubocurarine 80-120 240 renal doxacurium 90-120 100+ renal pipecuronium 80-100 137+ renal
  10. 10. Sedatives in ICU diazepam 50-120 Icp, cbf, lorazepam 3-7 midazolam 7-10 morphine 4-11 Cbf,icp fentanyl 10 thiopental 2-4 Cbf,icp,cpp phenobarbiton e 48-144 haloperidol 10-19 Cbf, cpp, icp propofol 40-50 Cbf,icp,cpp ketamine 2-14 Cbf,icp
  11. 11. Evaluation of comatose  Spontaneous activity, motor response, eye position and movements, pupillary reflexes, brainstem reflexes and asymmetry between right and left responses.  Decorticate (flexor) posturing-lesion above level of red nucleus.  Decerebrate posturing (extensor)-damage to lower midbrain or upperpons, severe damage and less chance of recovery.  Ciliospinal reflex
  12. 12. Main opthalmologic findings in comatose  Vitreous sub hyaloid haemorrages  Papilledema,retinal exudates&haemorrages  Papilledema  Cholesterol embolus  Subconjunctival hemorrage  Periorbital eccymoses, Battle sign -SAH -hypertensive encepalopathy -ICT increase -carotid atheroma -endocarditis -head trauma
  13. 13. Eye movements in coma  Conjugate horizontal roving  Conjugate horizontal ocular deviation  Wrong way eyes  Downward ,inward eyes  Ocular bobbing  Ocular dipping  Dysconjugate eye movemnts -Excludes midbrain, pons lesion -Contralateral pon/ipsilateral frontal -Paradoxically to,contralateral deep hemispheric leson. -Thalamic,upper midbrain lesion -Bilateral pontine damage -Diffuse cortical anoxia -Brainstem damage
  14. 14. Abnormal pupillary responses in coma Bilateral small ,reactive b/l dilated and unreactive b/l dilation&reactive Unilateral miosis Metabolic encephalopathy, B/l thalamic, pontine lesions, hydrocephalus,narcotics,OP,barbitur ates Midbrain damage or compression Seizure Thalamus, sympathetic efferents from posterior hypothalamus, tegmentum, descending to the cervical cord
  15. 15. Pupillary responses and coma Unilateral, unreactive & enlarged -unilateral ptosis -bilateral ptosis Unilateral,small,reactive, ipsilateral ptosis -with face anhydrosis -anhydrosis entire side of body -without anhydrosis Compression of ipsilateral III nerve -Fascicular lesion -Nuclear lesion -Extracranial defect T1-T2 to carotid bifurcation -Between hypothalamus and spinal cord -ICA vs cavernous sinus vs SOF vs orbit
  16. 16. Glasgow coma scale
  17. 17. FOUR score scale Eye response 4-eyelid open or opened, tracking or blinking to command 3-eyelids open, not tracking 2-eyelids closed, open to loud voice, not tracking 1-eyelids closed, open to pain, not tracking. 0-eyelids remain closed with pain Motor response 4-thumbs up, fist, or peace sign to command 3-localizing to pain 2-flexion response to pain 1-extensor posturing 0-no response to pain or generalized myoclonus/status Brainstem reflexes 4-pupil & corneal reflex present 3-open pupil wide & fixed 2-pupil/corneal reflexes absent 1-pupil & corneal reflex absent 0-absent pupil, corneal & cough reflexes Respiration 4-not intubated, regular breathing pattern 3-not intubated, cheyne-stokes breathing pattern 2-not intubated, irregular breathing pattern 1-breathes above ventilator rate 0-breathes at ventilator rate
  18. 18. Cerebral herniation :clinical syndromes Uncal herniation Hemispheric/later al middle fossa Ipsilateral III compression Dilated ipsilateral pupil with preserved or sluggish reaction to light. CnIII,ophthalmopl egia,ipsilateral hemipareis Central herniation Supra tentorial diffuse brain edema, haemorrage, midline tumors Initial obstruction hydrocephalus, thalamus, hypothalamus displacement Decrease consciousness, small & reactive pupils, normal eye movements. Fixed pupils, cheyne stroke respiration, opthalmoplegia, decorticate posturing
  19. 19. Cerebral herniation clincal syndromes Midbrain compression Advanced stage of central herniation, upward infra tentorial lesions Midbrain and upper pons Decerebrate posturing, midposition pupils, sometimes irregular and loss of pupillary, oculocephalic and oculo vestibular reflexes Foramen magnum herniation Infra tentorial lesions Medulla-lower pons, cerebellar tonsils All brainstem reflexes are lost, flaccid paralysis, ataxic respiration, then ceasing
  20. 20. Differential diagnosis in non neurological ICU Metabolic coma Structural coma
  21. 21. major causes of organic coma- supra tentorial  Unilateral Hemorrhagic contusion Subdural hematoma Epidural hematoma MCA occlusion & edema IC bleed Abscess tumor  Bilateral Traumatic injury Multiple infarcts (vasculitis coagulopaty, cardiac emboli) Bilateral thalamic infarct Primary lymphoma ADEM Anoxia Metastases Leucoencephalopathy(chemothe rapy,radiotherapy)
  22. 22. Major causes of organic coma- infratentorial  Brainstem pontine bleed basilar artery occlusion central pontine myelinolysis brainstem contusion  Cerebellum cerebellar infarct cerebellar bleed cerebellar abscess cerebellar tumour
  23. 23. Medical ICU  Metabolic encephalopathy-28.6%  Seizures-28.1%  Hypoxic ischemic encephalopathy-23.5%  Stroke-22.1%  Sepsis is major cause of neurological complication-38.8% Bleck et al-2 yr period
  24. 24. Primary CNS processes  Acute stroke-1-4% in non neuro icu. Angiographic studies De clotting of Av shunts Vascular line insertions Air embolism Cardioversion Anticoagulation Thrombolytic therapy
  25. 25. Primary CNS processes Meningitis & encephalitis-change in mental state with fever, csf analysis and antibiotics. Posterior reversible leuco encephalopathy-acute hypertensive crisis involving brain, vaso genic edema, control with labetolol, nicardipine etc.
  26. 26. Conditions associated with acute hypertensive crisis & hypertensive encephalopathy  Toxemia of pregnancy  Drugs-cyclosporine tacrolimus interferon fludarabine cisplatin gemcitabine erythropoetin Uncontrolled essential hypertension Secondary hypertension- SLE,AGN,CRF
  27. 27. Primary CNS processes  New onset seizure-0.8-4%,focal most common.  Myoclonic seizures-metabolic, drugs,hypoxia.  Non convulsive status-10%(50%of TBI), 52% mortality in critically ill  Myoclonic status epilepticus-12hrs of cardiac resuscitation, persists up to 48 hrs, poor prognostic sign, unresponsive to medication.
  28. 28. Common precipitants of seizures in ICU  Metabolic: renal, hepatic, electrolyte, Endocrine  Hypoxia/ischemia  Sepsis  Stroke  Primary CNS inflammations  Withdrawal delirium tremens BZD narcotics Drugs: Anti arrythmics- lidocaine, flecainide Antibiotics-imipenam, ciprofloxacin, norfloxacin, penicillin derivatives Antidepressants-amit, nortript,doxepin Bronchodilators-theophylline Immunosupressive drugs- cyclosporine,OTR3,FK506
  29. 29. Secondary CNS processes Encephalopathy is the most common neurological complication in medical ICU. Prolonged sedation Drug intoxication
  30. 30. Sodium disturbances  Hypo natremia-incidence of1%,prevalence of 2.5%. Postoperative patients Lethargy, confusion, coma ,seizures. Central pontine myelinolysis  Hypernatremia-increase use for ICT. Lethargy, obtundation, coma Progressive shrinkage of brain leading to cerebral vascular damage and sub dural hamatoma
  31. 31. Calcium disturbance Hyper calcemia- ionised calcium levels and rate of rise. Delirium, depression, coma. Hypo calcemia-commonly associated with sepsis. Irritabilty, tremors and seizures
  32. 32. Magnesium disturbances Hypo magnesemia-commonly associated with hypo calcemia. Tremor, tetany, myoclonus and seizures. Hyper magnesemia- cns depression with lethargy, confusion and weakness. Serum levels>6meq/l causes coma
  33. 33. Acid base disturbances  Severe acidemia- <7.2,metabolic,respiratory,mixed Increase of icp, decrease seizure thresold, stimulate chemoreceptor trigger zone.  Severe acute alkalemia-ph>7.60 Cerebral vasoconstriction, decreased oxygen extraction Respiratory depression, tetany,coma,siezures
  34. 34. renal  Uremic encephalopathy-BUN doubles, drowsiness, asterexis, myoclonus  Post dialysis disequilibrium-rapid dialysis, first dialysis, extreme baseline pre dialysis BUN Younger patients, previous neurological deficits Cerebral edema along osmotic gradient Combative behavior, headache, myoclonic jerks, cramps, cortical blindness, coma, seizures Avoided by continuous veno venous hemodialysis
  35. 35. liver Acute hepatic failure-hyper ammonemia, hepatic encephalopathy. Gr IV -80% mortality pH dependent partial pressure of gaseous ammonia from blood Hypoglycemia/hyperglycemia-confusion, coma, seizures, focal neurological deficits.
  36. 36. Hypoxic ischemic encephalopathy  Hypotension, hypoxemia, asphyxia, laryngeal edema Severity and duration of hypoxia Transient confusion, antegrade amnesia, focal, multi focal or global cns damage or brain death. Fixed pupils, myoclonic status, sustained upward gaze poor prognosis  Delayed post anoxic encephalopathy Lucid interval of 1-4 weeks Diffuse hemispheric demyelination, cognitive cerebellar, pyramidal and coma.
  37. 37. Sepsis encephalopathy Most common (70%) in medical icu. Highest mortality Multi organ failure Decreased cerebral O2 extraction ratios, disordered amino acid transport, micro abscesses, inflammatory mediators, dys regulation of neurotransmitters, direct cytotoxicity, disruption of blood brain barrier
  38. 38. Surgical ICU  Cholesterol embolisation-vascular catheterisation diffuse encephalopathy, retinal hemorrhage, transient hemiparesis, livedo reticularis, purple toes, renal failure, muscle weakness Muscle/renal biopsy-stacked needle shaped crystals  Fat embolism-trauma and long bone fracture/surgery  Multifocal ischemic stroke-Cardiothoracic surgery. watershed infarcts, LV thrombus, aortic atherosclerosis ,aortic cross clamping, infective endocarditis, arrythmias. MRI limited by pacemakers
  39. 39. Transplant ICU Transplant organ/procedure related Immunosuppressive therapy
  40. 40. Renal/liver transplantation Cutaneous neuropathies ad spinal cord infarction Re vascularisation procedure BP changes Hyper coagulabilty-secondary to rapid correction of uremia Increase in ICT during postoperative anicteric phase
  41. 41. Cardiac/BMT Single/multiple cerebral infarctions- emboli, global hypo perfusion, arrhythmias, bypass pump, supra therapeutic heparin Infections, Hippocampal damage Bmt-37% met encephalopathy, CNS infection with minimal signs
  42. 42. cyclosporine Tremor and restlessness Syndome1-confusion,cortical blindness, visual hallucinations Syndrome2-ataxia,cerebellar tremor, and focal weakness Within 2 weeks, IV,normal levels Psychosis, mutism, central pontine myelinolyis,actionmyoclonus.
  43. 43. Tacrolimus/muromonab  Fine tremor, paresthesias, apraxia, aphasia, akinetic mutism. Cortical blindness, CIDP  Aseptic meningitis and toxic encephalopathy Csf pleocytosis with neutrophil predominance, mild protein elevation, normal glucose and sterile cultures Seizures, psychosis, visual loss
  44. 44. Offering prognosis  Etiology, severity, secondary CNS damage, age.  5-pont Glasgow outcome scale,6-point pediatric cerebral performance category scale, GCS, FOUR score-motor score, sphincter conrol, self care, communication, pupillary reactivity  Children and young adults, toxic or metabolic abnormalities-better  Absence of brainstem reflexes, low GCS, hypoxia ,hypotension-worst  MRI,MRS, DTI.
  45. 45. Anoxic coma  Pupils, corneal reflex, motor response to pain ,myoclonic status, SSEP, serum neuron specific enolase.  No response or extension to pain, EEG with malignant characteristics, absent bilateral ssep-poor prognosis  Elevated NSE at 24 and 48 hrs >33ng/ml -poor prognosis  EEG with alternating high voltage slow waves with low voltage irregular fast activity-good prognosis
  46. 46. Brain death and organ donation  Irreversible loss of brain function including brainstem  Traumatic brain injury and SAH  Prerequisites to diagnosis  Identify patients who are likely to progress to brain death  Consent, ethical  Optimize and treat any physiological disturbance associated with brain death to protect organs for transplantation
  47. 47. hypothermia  To minimize secondary brain damage  Avoid hyperthermia-excito toxicity, free radical generation, inflammation, apoptosis.  Therapeutic hypothermia-core body temp <33 c  Massive ischemic stroke, TBI, anoxia  External cooling devices, iv cold saline infusions, iv cooling catheters.  Electrolyte abnormalities, cardiac arrhythmia,infection.
  48. 48. Thank you

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