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COMA
DIAH MUSTIKA HW,SpS,KIC
INTENSIVE CARE UNIT of EMERGENCY DEPARTMENT
NAVAL HOSPITAL dr RAMELAN, SURABAYA
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
• ARAS : rostral pons, midbrain, thalamus, hypothalamus
• Wakefullness or alertness Arousal
• Cerebral cortex and connection to subcortical white matter
• Attention, memory,motivation and executive function
Content
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
Levels of Arousal:
Motor
Response Example Score
Commands Follows simple commands 6
Localizes
Pain
Pulls examiner's hand away
when pinched 5
Withdraws
from Pain
Pulls a part of body away when
pinched 4
Abnormal
Flexion
Flexes body inappropriately to
pain 3
Abnormal
Extension
Body becomes rigid in an
extended position when
examiner pinches him 2
No Response Has no motor response to pinch 1
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
Verbal Response
(Talking) .
Orientated
Carries on a conversation
correctly and tells examiner
where he is, who he is, and
the month and year 5
Confused
Conversation
Seems confused or
disoriented 4
Inappropriate Words
Talks so examiner can
understand him but makes
no sense 3
Sounds
Makes sounds that
examiner cannot understand 2
No Response Makes no noise 1
EMERGENT MANAGEMENT
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
Evaluation:
• History
• Physical Exam
• Laboratory and Imaging Studies
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:
Evaluation—Physical Exam:
• Systemic
– Vital Signs
– Signs of trauma
– Signs of infection
– Signs of bleeding
– Signs of other systemic illnesses
Evaluation—Physical Exam:
• Rapid Neurologic Exam:
– Pupils
– Respiratory pattern
– Stimuli needed to elicit response
– Character of the response
Neurologic Exam—Pupils:
Respiratory patterns:
Cheyne-Stokes
Central
Hyperventilation
Apneustic
Cluster
breathing/Gasping
Agonal breathing
Hemispheric
Midbrain
Mid/Lower Pons
Low Pons/Upper
Medulla
Medulla
Location Pattern
Posturing:
Decorticate
lesion above
midbrain
Decerebrate
lesion below
midbrain
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
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
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
Thanks for your attention