COMA. DIAH MUSTIKA HW,SpS,KIC INTENSIVE CARE UNIT of EMERGENCY DEPARTMENT
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1 COMA DIAH MUSTIKA HW,SpS,KIC INTENSIVE CARE UNIT of EMERGENCY DEPARTMENT NAVAL HOSPITAL dr RAMELAN, SURABAYA
2 DEFINITIONS Coma State of unresponsiveness to external or internal stimuli in which a patient lies w/ eyes closed unaware of the environment Consciousness State of awareness of both the self and the environment
3 Arousal ARAS : rostral pons, midbrain, thalamus, hypothalamus Wakefullness or alertness Content Cerebral cortex and connection to subcortical white matter Attention, memory,motivation and executive function
4 Levels of Arousal: Alert : fully consciousaalert: Fully conscious Lethargic: appear somnolent, but may be able to maintain arousal spontaneously or with repeated light stimulation Obtunded: requires touch or voice to maintain arousal Stuporous: unresponsiveness from which the individual can be aroused only by vigorous and repeated stimulus Comatose: state of unarousable unresponsiveness in which individual lies with eyes closed, lacking awareness of self and environment
5 Motor Response Example Score Commands Follows simple commands 6 Localizes Pain Withdraws from Pain Abnormal Flexion Abnormal Extension Pulls examiner's hand away when pinched 5 Pulls a part of body away when pinched 4 Flexes body inappropriately to pain 3 Body becomes rigid in an extended position when examiner pinches him 2 No Response Has no motor response to pinch 1
6 Eye-Opening. Spontaneous Opens eyes on own 4 To Voice Opens eyes when asked to in a loud voice 3 To Pain Opens eyes when pinched 2 No Response Does not open eyes 1
7 Verbal Response (Talking). Orientated Confused Conversation Inappropriate Words Sounds Carries on a conversation correctly and tells examiner where he is, who he is, and the month and year 5 Seems confused or disoriented 4 Talks so examiner can understand him but makes no sense 3 Makes sounds that examiner cannot understand 2 No Response Makes no noise 1
8 EMERGENT MANAGEMENT
9 Stabilization: Airway Assess for patency Assess for ability to protect Breathing Assess ventilation Assess breathing pattern Circulation Assess measures of cardiac output Hyper or hypothermia should reversed appropriately to normothermia
10 Evaluation: History Physical Exam Laboratory and Imaging Studies
11 Evaluation History: Rapid initial history: Recent history prior to mental status changes Past medical history (seizures) Family history (specifically seizures/neurologic disorders) Trauma? Febrile? / Other signs or symptoms of infection Diet Exposure to drugs/toxins Follow-up with more complete history:
12 Evaluation Physical Exam: Systemic Vital Signs Signs of trauma Signs of infection Signs of bleeding Signs of other systemic illnesses
13 Evaluation Physical Exam: Rapid Neurologic Exam: Pupils Respiratory pattern Stimuli needed to elicit response Character of the response
14 Neurologic Exam Pupils:
15 Respiratory patterns: Location Hemispheric Midbrain Mid/Lower Pons Low Pons/Upper Medulla Medulla Pattern Cheyne-Stokes Central Hyperventilation Apneustic Cluster breathing/gasping Agonal breathing
16 Posturing: Decorticate lesion above midbrain Decerebrate lesion below midbrain
17 Common etiologies of coma Structural Lesions Supratentorial Generalized/bilateral Infectious/positinfectious Encephalitis Acute disseminated encephalomyelitis Vascular Anoxic ischmenic encephalopathy Multiple cortical infarctions Bilateral thalamic infarctions Traumatic Diffuse axonal injury Penetrating brain injury Multiple contusions Neoplastic Glimatosis Leukoencephalopathy Multiple brain metastases Lymphoma
18 Focal (with mass effect) Intraparenchymal hematoma Large stroke with edema Abscess Tumor Infratentorial Brain stem Pontine hemorrhage Basilar artery thrombis Central pontine myelinolysis Cerebellum Infraction with edema Hematoma Abscess Tumor Metabolic derangements Hypoglycemia Hyperglycemia (nonketotic hyperosmolar) Hyponatremia Hypercalcemia Panhypopituitarism Hyperbilirubinemia Acute uremia
19 Diffuse Physiologic Brain Dysfunction Status epilepticus Poisoning Drug overdose Gas inhalation Hypotthermia Basiliar migraine Malignant neuroleptic syndrome Hypoxia Psychogenic Unresponsiveness Catatonia Conversion disorder Malingering Adapted from Ziai WC. Coma and altered consciousness. In Bhardwaj A, Mirski MS, Ulatowski JA (eds), Current Clinical Neurology : Handbook of Neurocritical Care. Totowa, NJ : Humana Press, 2004, pp 1 18
20 Thanks for your attention
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