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. ARAS : rostral pons, midbrain, thalamus, hypothalamus Wakefullness or alertness Cerebral cortex and connection to subcortical white matter Attention, memory,motivation and executive function Arousal Content

4.  Alert : fully conscious AAlert: 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 Levels of Arousal:

5. Motor Response ExampleScore CommandsFollowssimplecommands6 Localizes Pain Pullsexaminer'shandaway whenpinched 5 Withdraws fromPain Pullsapartofbodyawaywhen pinched 4 Abnormal Flexion Flexesbodyinappropriatelyto pain 3 Abnormal Extension Bodybecomesrigidinan extendedpositionwhen examinerpincheshim 2 NoResponseHasnomotorresponsetopinch1

6. Eye-Opening. SpontaneousOpenseyesonown4 ToVoice Openseyeswhenaskedto inaloudvoice 3 ToPainOpenseyeswhenpinched2 NoResponseDoesnotopeneyes1

7. VerbalResponse (Talking). OrientatedCarriesonaconversation correctlyandtellsexaminer whereheis,whoheis,and themonthandyear 5 Confused Conversation Seemsconfusedor disoriented 4 InappropriateWordsTalkssoexaminercan understandhimbutmakes nosense 3 Sounds Makessoundsthat examinercannotunderstand 2 NoResponseMakesnonoise1

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 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 yourattention