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MANAGEMENT AND MANAGEMENT AND EVALUATION OF THE EVALUATION OF THE COMATOSE PATIENTCOMATOSE PATIENT

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OBJECTIVESOBJECTIVES• Primary Objective: The physician Primary Objective: The physician

should be able to stabilize, evaluate, should be able to stabilize, evaluate, and treat the comatose patient in the and treat the comatose patient in the emergent setting. emergent setting.

• The physician should understand this The physician should understand this involves an organized, sequential, involves an organized, sequential, prioritized approach.prioritized approach.

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The Comatose PatientThe Comatose Patient

Primary ObjectivesPrimary Objectives• AAirwayirway• BBreathingreathing• CCirculationirculation• Treatment of rapidly progressive, dangerous Treatment of rapidly progressive, dangerous

metabolic causes of coma (hypoglycemia)metabolic causes of coma (hypoglycemia)• Evaluation as to whether there is significant Evaluation as to whether there is significant

increased ICP or mass lesions.increased ICP or mass lesions.• Treatment of ICP to temporize until surgical Treatment of ICP to temporize until surgical

intervention is possible.intervention is possible.

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The Comatose PatientThe Comatose Patient

Secondary ObjectivesSecondary Objectives• The physician should understand and The physician should understand and

recognize:recognize:•ComaComa•Herniation syndromesHerniation syndromes•Signs of supratentorial mass lesionsSigns of supratentorial mass lesions•Signs of subtentorial mass lesionsSigns of subtentorial mass lesions

• The physician should be able to The physician should be able to develop the differential diagnosis of develop the differential diagnosis of metabolic coma.metabolic coma.

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PICU The Comatose PatientThe Comatose Patient

NeurophysiologyNeurophysiology

• Consciousness requires:Consciousness requires:•An intact pontine reticular activating An intact pontine reticular activating systemsystem

•An intact cerebral hemisphere, or at An intact cerebral hemisphere, or at least part of a hemisphereleast part of a hemisphere

• Coma requires dysfunction of either the:Coma requires dysfunction of either the:•Pontine reticular activating system, Pontine reticular activating system, oror•Bihemispheric cerebral dysfunctionBihemispheric cerebral dysfunction

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The Comatose PatientThe Comatose PatientClassificationsClassifications• SupratentorialSupratentorial lesions cause coma by either lesions cause coma by either

widespread bilateral disease, increased widespread bilateral disease, increased intracranial pressure, or herniation.intracranial pressure, or herniation.

• InfratentorialInfratentorial lesions involve the RAS, lesions involve the RAS, usually with associated brainstem signsusually with associated brainstem signs

• MetabolicMetabolic coma causes diffuse hemispheric coma causes diffuse hemispheric involvement and depression of RAS, involvement and depression of RAS, usuallyusually without focal findingswithout focal findings

• PsychogenicPsychogenic

Plum and Posner, 1982

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LesionsLesions• HematomaHematoma• NeoplasmNeoplasm• AbscessAbscess• ContusionContusion• Vascular AccidentsVascular Accidents• Diffuse Axonal DamageDiffuse Axonal Damage

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Supratentorial Mass LesionsSupratentorial Mass LesionsSubdural HematomaSubdural Hematoma

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Acute epidural hematoma and midline Acute epidural hematoma and midline shiftshift

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PICU Severe head trauma with basilar skull Severe head trauma with basilar skull

fracture, right temporal hematoma, cerebral fracture, right temporal hematoma, cerebral edema, hydrocephalus, and pneumocephalusedema, hydrocephalus, and pneumocephalus

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Supratentorial Mass LesionsSupratentorial Mass Lesions Cerebral AbscessCerebral Abscess

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Supratentorial Mass LesionsSupratentorial Mass LesionsPathophysiologyPathophysiology• Altered consciousness is based onAltered consciousness is based on

•Increased intracranial pressureIncreased intracranial pressure•Herniation Herniation •Diffuse bilateral lesionsDiffuse bilateral lesions

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Herniation SyndromesHerniation SyndromesCentral herniation Central herniation

Rostral caudal progression of Rostral caudal progression of respiratory, motor, and pupillary respiratory, motor, and pupillary findingsfindingsMay not have other focal findingsMay not have other focal findings

Uncal herniationUncal herniationRostral caudal progression Rostral caudal progression CN III dysfunction and contralateral CN III dysfunction and contralateral motor findingsmotor findings

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Herniation syndromesHerniation syndromes

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Normal AnatomyNormal Anatomy

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Transtentorial HerniationTranstentorial Herniation

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Normal BrainNormal Brain

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Transtentorial herniation and brainstem Transtentorial herniation and brainstem infarction in a patient with melanomainfarction in a patient with melanoma

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Supratentorial Mass LesionsSupratentorial Mass LesionsDifferential CharacteristicsDifferential Characteristics

Initiating signs usually of focal cerebral Initiating signs usually of focal cerebral dysfunctiondysfunctionSigns of dysfunction progress rostral to Signs of dysfunction progress rostral to caudalcaudalNeurologic signs at any given time Neurologic signs at any given time point to one anatomic area - point to one anatomic area - diencephalon, midbrain, brainstemdiencephalon, midbrain, brainstemMotor signs are often asymmetricalMotor signs are often asymmetrical

Plum and Posner, Plum and Posner, 19821982

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ProgressionProgression

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Rostral Caudal ProgressionRostral Caudal Progression

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Rostral Caudal ProgressionRostral Caudal Progression

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Infratentorial LesionsInfratentorial Lesions• Cause coma by affecting reticular Cause coma by affecting reticular

activating system in ponsactivating system in pons• Brainstem nuclei and tracts usually Brainstem nuclei and tracts usually

involved with resultant focal involved with resultant focal brainstem findingsbrainstem findings

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Infratentorial LesionsInfratentorial LesionsCauses of ComaCauses of Coma• NeoplasmNeoplasm• Vascular accidentsVascular accidents• TraumaTrauma• Cerebellar hemorrhageCerebellar hemorrhage• Demyelinating diseaseDemyelinating disease• Central pontine myelinolysis (rapid Central pontine myelinolysis (rapid

correction of hyponatremia)correction of hyponatremia)

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Infratentorial Mass LesionsInfratentorial Mass LesionsDifferential CharacteristicsDifferential Characteristics• History of preceding brainstem History of preceding brainstem

dysfunction or dysfunction or sudden onset sudden onset of comaof coma• Localizing brainstem signs Localizing brainstem signs precede or precede or

accompany onset of coma and always accompany onset of coma and always include oculovestibular abnormalityinclude oculovestibular abnormality

• Cranial nerve palsies Cranial nerve palsies usually presentusually present• ““Bizarre” respiratory patterns Bizarre” respiratory patterns common, common,

usually present at onset of comausually present at onset of coma

Plum and Posner, 1982Plum and Posner, 1982

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Metabolic ComaMetabolic ComaEtiologiesEtiologies• RespiratoryRespiratory

– HypoxiaHypoxia– HypercarbiaHypercarbia

• ElectrolyteElectrolyte– HypoglycemiaHypoglycemia– HyponatremiaHyponatremia– HypercalcemiaHypercalcemia

•Hepatic Hepatic encephalopathyencephalopathy

•Severe renal Severe renal failurefailure

•InfectiousInfectious– MeningitisMeningitis– EncephalitisEncephalitis

•Toxins, drugsToxins, drugs

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Metabolic ComaMetabolic ComaDifferentiating FeaturesDifferentiating Features• Confusion and stupor commonly precede Confusion and stupor commonly precede

motor signsmotor signs• Motor sings are usually symmetricalMotor sings are usually symmetrical• Pupillary reactions are usually preservedPupillary reactions are usually preserved• Asterixis, myoclonus, tremor, and Asterixis, myoclonus, tremor, and

seizures are commonseizures are common• Acid-base imbalance with hyper- or Acid-base imbalance with hyper- or

hypoventilation is frequenthypoventilation is frequent

Plum and Posner, 1982Plum and Posner, 1982

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Approach to the Comatose PatientApproach to the Comatose PatientPrioritiesPriorities• ABC’s are paramount!ABC’s are paramount!• Must prioritizeMust prioritize• Must ensure oxygen and substrate Must ensure oxygen and substrate

reach CNS and vital organs reach CNS and vital organs • Must address immediately life Must address immediately life

threatening conditions before threatening conditions before addressing CNS addressing CNS

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Approach to the Comatose PatientApproach to the Comatose PatientInitial TreatmentInitial Treatment• AirwayAirway• BreathingBreathing• CirculationCirculation• ABC - identify and address life ABC - identify and address life

threatening inadequaciesthreatening inadequacies• Treat rapidly progressive metabolic Treat rapidly progressive metabolic

disorders -- hypoglycemiadisorders -- hypoglycemia• Evaluate for intracranial hypertension Evaluate for intracranial hypertension

and imminent herniation and treatand imminent herniation and treat

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Management of the Comatose Patient Management of the Comatose Patient AirwayAirway• Evaluate -- is airway patent. Can patient Evaluate -- is airway patent. Can patient

move air without obstruction. Is there move air without obstruction. Is there trauma or foreign body obstructing trauma or foreign body obstructing airwayairway

• Try chin lift to help open airway -- Try chin lift to help open airway -- protect cervical spineprotect cervical spine

• Place airway if indicated - nasal or oral Place airway if indicated - nasal or oral airway, intubation, or surgical airwayairway, intubation, or surgical airway

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Management of the Comatose PatientManagement of the Comatose Patient AirwayAirway• Intubate (protecting neck) “Intubate (protecting neck) “anyone who anyone who

will let you”will let you”– Any of the following are adequate criteriaAny of the following are adequate criteria

•GCS < 9GCS < 9•Airway not secure or openAirway not secure or open•Respiration not adequateRespiration not adequate•Any significant respiratory failureAny significant respiratory failure•Uncertainty regarding direction or rate of Uncertainty regarding direction or rate of

mental status changes, particularly if mental status changes, particularly if constant observation not available (during constant observation not available (during CT scans, etc..)CT scans, etc..)

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Management of the Comatose Patient Management of the Comatose Patient BreathingBreathing• Evaluate - is patient moving adequate Evaluate - is patient moving adequate

air, is respiratory rate appropriate, is air, is respiratory rate appropriate, is gas exchange adequate, are breath gas exchange adequate, are breath sounds adequate and symmetricalsounds adequate and symmetrical

• Must assure oxygenation and ventilationMust assure oxygenation and ventilation• If intubated don’t forget to ventilateIf intubated don’t forget to ventilate• Identify and immediately treat problems Identify and immediately treat problems

- pneumothorax, airway obstruction, - pneumothorax, airway obstruction, etc..etc..

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Management of the Comatose PatientManagement of the Comatose PatientCirculationCirculation• Is patient in shock? Is patient in shock?

•Check pulses, heart rate, blood pressure, Check pulses, heart rate, blood pressure, perfusionperfusion

•Remember hypotension is Remember hypotension is latelate sign of sign of shockshock

• Start treatment for shockStart treatment for shock•Do not restrict fluids in comatose patient Do not restrict fluids in comatose patient

with inadequate intravascular volume. with inadequate intravascular volume. •Cardiac output and cerebral perfusion are Cardiac output and cerebral perfusion are

much more important than fluid restrictionmuch more important than fluid restriction

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Management of the Comatose PatientManagement of the Comatose PatientCirculationCirculation• Use isotonic solutions and blood, as Use isotonic solutions and blood, as

indicated.indicated.• Do not use hypotonic solutions to treat Do not use hypotonic solutions to treat

shock, particularly patients with coma shock, particularly patients with coma or possible cerebral edemaor possible cerebral edema

• Identify life threatening hemorrhage Identify life threatening hemorrhage and control it.and control it.

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Management of the Comatose PatientManagement of the Comatose PatientDisability - NeurologicDisability - Neurologic• Glasgow coma scaleGlasgow coma scale

– Provides easily reproducible and somewhat Provides easily reproducible and somewhat predictive basic neurologic exampredictive basic neurologic exam

– This allows rapid assessment and record of This allows rapid assessment and record of baseline neurologic statusbaseline neurologic status

– Allows physician to track neurologic changes Allows physician to track neurologic changes over time and multiple examinersover time and multiple examiners

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Glasgow Coma ScaleGlasgow Coma Scale• Three components. Score derived by Three components. Score derived by

adding the score for each component.adding the score for each component.

•Eye opening (4 points)Eye opening (4 points)•Verbal response (5points)Verbal response (5points)•Best motor response (6 points)Best motor response (6 points)

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Glasgow Coma ScaleGlasgow Coma Scale• Eye openingEye opening

• 4 - spontaneous4 - spontaneous• 3 - to speech3 - to speech• 2 - to pain2 - to pain• 1 - none1 - none

• Verbal ResponseVerbal Response• 5 - oriented5 - oriented• 4 - confused conversation4 - confused conversation• 3 - inappropriate words3 - inappropriate words• 2 - incomprehensible sounds2 - incomprehensible sounds• 1 - none1 - none

• Best Motor ResponseBest Motor Response• 6 - obeys6 - obeys• 5 - localizes5 - localizes• 4 - withdraws4 - withdraws• 3 - abnormal 3 - abnormal

flexionflexion• 2 - abnormal 2 - abnormal

extensionextension• 1 - none1 - none

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PICU Management and Evaluation of the Comatose Management and Evaluation of the Comatose

PatientPatientPracticalitiesPracticalities• During ABC’s and secondary survey:During ABC’s and secondary survey:

– Have someone start IV and obtain labsHave someone start IV and obtain labs•ABG’sABG’s•Chem 7, LFT’s, ammonia, coagulation studiesChem 7, LFT’s, ammonia, coagulation studies• Toxin screensToxin screens•DextrostickDextrostick

– As soon as IV in and labs drawn, giveAs soon as IV in and labs drawn, give•Glucose (D25, 2 - 4 cc per kilogram)Glucose (D25, 2 - 4 cc per kilogram)•Consider thiaminConsider thiamin

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Management of the Comatose PatientManagement of the Comatose PatientSecondary SurveySecondary Survey• Do a quick general exam of the entire Do a quick general exam of the entire

body to identify acute life threatening body to identify acute life threatening conditionsconditions

• In general, major thoracic or abdominal In general, major thoracic or abdominal trauma takes precedence after ABC’strauma takes precedence after ABC’s

• Only very rarely is acute neurosurgical Only very rarely is acute neurosurgical intervention appropriate before other intervention appropriate before other acute life threatening injuries are acute life threatening injuries are stabilized (except protection of c spine by stabilized (except protection of c spine by immobilization)immobilization)

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Neurologic ExaminationNeurologic ExaminationSecondary SurveySecondary Survey• General motor examGeneral motor exam

– look for focal deficits, posturing (decerebrate or look for focal deficits, posturing (decerebrate or decorticate)decorticate)

• Reflexes, toneReflexes, tone• Cranial nerve and brainstem functionCranial nerve and brainstem function

– Pupillary response - diencephalon, midbrain, Pupillary response - diencephalon, midbrain, brainstem, CN’s II and IIIbrainstem, CN’s II and III

– Corneal Reflex - CN’s V, VII, brainstemCorneal Reflex - CN’s V, VII, brainstem– Oculocephalic Reflex - not if neck injury possible. Oculocephalic Reflex - not if neck injury possible.

Tests CN’s III, IV, VI, VIII, and brainstem.Tests CN’s III, IV, VI, VIII, and brainstem.– Oculovestibular (calorics) can be done if neck Oculovestibular (calorics) can be done if neck

questionable.questionable.

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Neurologic ExamNeurologic ExamOculovestibular TestingOculovestibular Testing• Check for tympanic perforationCheck for tympanic perforation• Instill 120 cc cold water over 2 minutesInstill 120 cc cold water over 2 minutes• Conscious patient - COWSConscious patient - COWS• Coma with intact pathways - tonic eye Coma with intact pathways - tonic eye

deviation to side of colddeviation to side of cold

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PICU Management and Evaluation Management and Evaluation

of the Comatose Patientof the Comatose Patient• Does the patient have a rapidly Does the patient have a rapidly

progressive intracranial lesion?progressive intracranial lesion?• Assume yes, if:Assume yes, if:

– 1. Any evidence of brainstem abnormality1. Any evidence of brainstem abnormality– 2. Any evidence of rostral caudal 2. Any evidence of rostral caudal

progressionprogression– 3. Any focal deficits3. Any focal deficits– 4. Progression of motor exam from 4. Progression of motor exam from

withdrawal to posturingwithdrawal to posturing

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progressive intracranial lesion?progressive intracranial lesion?

• If any factor is present, assume If any factor is present, assume increased intracranial pressure is increased intracranial pressure is present and herniation and irreversible present and herniation and irreversible damage imminentdamage imminent– IntubateIntubate– HyperventilateHyperventilate– MannitolMannitol– CT scan, neurosurgical consultationCT scan, neurosurgical consultation

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Does the patient have a rapidly Does the patient have a rapidly progressive intracranial lesion?progressive intracranial lesion?• If none of the findings are present, If none of the findings are present,

surgical lesion less likely than metabolic surgical lesion less likely than metabolic causecause

• Mass lesion still possible, though - CT scanMass lesion still possible, though - CT scan• Urgency of intubation less but should Urgency of intubation less but should

considerconsider– Will patient deteriorate, particularly while out Will patient deteriorate, particularly while out

of constant observation (CT scanner)?of constant observation (CT scanner)?– Can patient protect airway?Can patient protect airway?

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the

PICU Management and Evaluation of the Comatose Management and Evaluation of the Comatose

PatientPatientAdditional PointsAdditional Points• If scans normal, probably metabolicIf scans normal, probably metabolic• Emergent causes of metabolic coma Emergent causes of metabolic coma

(even after ABC’s)(even after ABC’s)– Hypoglycemia - give glucoseHypoglycemia - give glucose– Infection - LP, consider antibiotics, acyclovir. Infection - LP, consider antibiotics, acyclovir.

If diagnostic studies delayed, treat firstIf diagnostic studies delayed, treat first– Certain toxins - antidepressants, salicylates, Certain toxins - antidepressants, salicylates,

theophylline, alcohol (methanol and ethylene theophylline, alcohol (methanol and ethylene glycol)glycol)

– Subclinical status epilepticusSubclinical status epilepticus