COMA.

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Presentation transcript:

COMA

Objectives To roughly understand the anatomical basis of Consciousness To know the common causes of coma To know the basic management of patients with coma.

Definition Consciousness? A state of awareness of self and environment and responsiveness to external stimulation and inner need. - Adams -

Aetiology Metabolic -extrinsic: Alcohol substance abuse Drugs heavy metals and poisons

Aetiology Metabolic -intrinsic: fluid (Shock) and electrolytes Nutritional Endocrine Organ failure

Aetiology Structural - Supratentorial Traumatic Vascular Inflammatory Neoplastic Degenerative

Aetiology Structural - Infratentorial Traumatic Vascular Inflammatory Neoplastic Degenerative

Brain Herniation Supratentorial herniation Uncal (transtentorial) Central Cingulate (subfalcine) Transcalvarial Infratentorial herniation Upward (upward cerebellar or upward transtentorial) Tonsillar (downward cerebellar)

Workup How bad it is? Is it Coma? Is it metabolic x Structural? Supra x Infra _tentorial?

Workup ABC History [Hypoglycemia, B1 def., Narcotic, Benzodiazipine]  immediate correction Physical examination

Workup Physical examination Medical exam. Neurological exam.

Neuro-exam Goals -functional assessment! -Is there structural brain damage? -Supra x Infra tentorial? -Differential diagnosis of Coma

Neuro-exam Consciousness: Responses to painful stimuli? R/O locked in state, Vegetative state, Minimally conscious state Glasgow-Coma scale

Neuro-exam Ocular: Hutchison's pupil -uncal herniation Miotic sluggishly reacting to light – pontine Midsized or Mydriatic fixed to light – Midbrain

Neuro-exam Oculo-cephalic Vestibulo-ocular

Neuro-exam Rest of Cranials: -Fundoscopy -V: blink -VII: cheeks and Eyes: Eyelid release test -Gag

Neuro-exam Respiratory patterns: Poorly localizing Cheyne-Stokes : Supra-tentorial /metabolic Central neurogenic hyperventilation: Midbrain/pons Apneustic (short-cycle Cheyne-Stokes): pons/medulla Ataxic (Biot): medulla Intermittent: medulla

Neuro-exam Motor system Signs of hemiplegia -wrist-dropping test Arm-dropping test Legs-dropping test Driven postures: Decorticate, Decerebrate.

Neuro-exam Meningeal Irritation Signs - Neck stiffness -Kernig’s sign -Brudzniski’

Further assessment . Investigations -Blood -Bed side -Imaging -Toxicology

Management Specific: Treat the cause Non specific: ABC, Feeding, Positioning, physiotherapy, monitoring, nursing care, etc…

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