NEUROEMERGENCYAND

UNCONSCIOUSNESS

Abdul GofirNeurology Department

Medical Faculty Gadjah Mada University

Anatomy and Physiology

Brain Death Current Consensus

Absent Cerebral Function

Absent Brainstem Function

Apnea

Normal Brain Anatomy

Normal Brain Anatomy

Cerebral Cortex

Brain Stem

Reticular Activating System

Cerebral CortexCognitionVoluntary

MovementSensation

Brain Stem

Brain Stem

Midbrain

Cranial Nerve III

pupillary function

eye movement

Brain Stem

Pons

Cranial Nerves IV, V, VI

conjugate eye movement

corneal reflex

Brain Stem

Medulla

Cranial Nerves IX, X

Pharyngeal (Gag) Reflex

Tracheal (Cough) Reflex

Respiration

Reticular Activating System

Receives multiple sensory inputs

Mediates wakefulness

Causes of Brain Death

Normal Cerebral Anoxia

Causes of Brain Death

Normal Cerebral Hemorrhage

Causes of Brain Death

Normal Subarachnoid Hemorrhage

Causes of Brain Death

Normal Trauma

Causes of Brain Death

Normal Meningitis

Mechanism of Cerebral Death

Neuronal Injury

Decreased Intracranial Blood Flow

Neuronal Swelling

Increased Intracranial Pressure

ICP>MAP is incompatible with life

Conditions Distinct From Brain Death

Persistent Vegetative State

Locked-in Syndrome

Minimally Responsive State

Persistent Vegetative State

Normal Sleep-Wake Cycles

No Response to Environmental Stimuli

Diffuse Brain Injury with Preservation of Brain Stem Function

Locked-in SyndromeVentral Pontine Infarct

Complete Paralysis

Preserved Consciousness

Preserved Eye Movement

Minimally Responsive State

Diffuse or Multi-Focal Brain Injury

Preserved Brain Stem Function

Variable Interaction with Environmental Stimuli

Static Encephalopathy

Clues from HistoryOnset of symptoms

sudden onsetfluctuations

Associated neurologic symptomsMedications

Neurologic ExamAssessmentDescriptive, systematicReference point for serial assessment

Exam goalsPrimary CNS event versus secondaryImplications:

short and long-term outcomeinvestigations

BreathingAbnormalities of respiration can help localize

but almost always in the context of other signsCentral-reflex Hyperpnea (midbrain-

hypothalamus)Apneustic, cluster, Ataxic (Lower pons)Loss of automatic breathing (medulla)

Cranial Nerve ExamSystematic assessment of brainstem function

via reflexesCranial Nerve Exam

Pupillary light response (CN 2-3)Occulocephalic/calorics (CN 3,4,6,8)Corneal reflex (CN 5,7)Gag refelx (CN 9,10)

.Pupillary Light ResponsesAfferent Limb: Optic NerveEfferent Limb: Parasympathetics via

occulomotorMidbrain integrity/ tectumUncal Herniation (3rd nerve dysfunction)Pupillary resistance to insult

Pupillary Light ResponsesBe aware of drug effects

Systemic and LocalState size, before and after light stimulationSpecify right and left

Pupils: Localizing ValuePons-pinpoint pupils

Symp. Dysfinction plus parasymp.irritationMidbrain-Large fixed pupils unresponsive to

light, hippusHorner’s- symp.dysfunctionUnilateral dilation- parasymp. Dysfunction

usually due to 3rd nerve lesion

Ciliospinal Reflex1-2 mm pupillary dilatation evoked by

noxious cutaneous stimulationMore prominent in sleep or coma than

during wakefulnessTest integrity of symp.pathways in comatose

patientsNot particularly useful in evaluating

brainstem function

Corneal ReflexAfferent: Trigeminal NerveEfferent: Third Nerve (Bell’s Phenomenon and Facial Nerve (Eye closure)Tests dorsal midbrain (Bell’s) and pontine

integrity (Eye closure)

Eye MovementsBefore maneuvers attempted note resting

positionMidline

Deviation suggests frontal/pontine damageConjugate

Dysconjugance suggests CN abn.Moving

Roving, dipping, bobbing

Occulocephalic/ CaloricsSame reflex elicited differentlyAfferent: Eighth nerveEfferent: 3,4,6 via MLF and PPRFOcculocephalics may also involve

proprioceptive afferents from the neck

Occulcephalic ReflexBrisk rotation of head with eyes held openWatch for contraversive movementsNext:

Flexion: eyes deviate up and eyelids open (doll’s head phenomenon)

Extension:eyes deviate downward

Caloric reflexEnsure TM integrityElevation of head to 30 degrees (so that

lateral semicircular canal is vertical)Instillation of up to 120 ml of ice water

Awake: deviation toward,nystagmus awayComatose: deviation toward

Wait 5 minutes, do other ear

CaloricsWatch for conjugance of deviationTo test vertical eye movements

Both ears, cold water-downward gazeBoth ears, warm water-upward gaze

Gag ReflexAfferent: GlossopharyngealEfferent: VagusTaken in context of other findings

Motor ExamAssess tone, presence of asterixisResponse to painful stimuli

noneabnormal flexorabnormal extensornormal localization/withdrawal

Avoid use of decerebrate/ decorticate

ReflexesBrainstemDeep tendon

Biceps, brachioradialis, tricepsPatellar, AchillesPlantar Responses

Superficial skinAbdominal, cresmasteric

Uncal herniaitonExpanding lesions in lateral middle fossaCompression of hippocampal gyrus over free

edge of tentoriumThree stages described

Early third nerveLate third nerveMidbrain-Upper pons stage

Goals in EmergencyPrimary Neurological Process?

evidence of raised ICPfocal findings, especially that implicate

brainstem structuresSecondary Processes

signs of infection, toxic/metabolic processesrelative lack of focality

Akinetic mutism ‘Locked-in’ syndrome Catatonia Conversion reactions

Akinetic MutismSilent, immobile but alert appearingUsually due to lesion in bilateral mesial

frontal lobes, bilateral thalamic lesions or lesions in peri-aqueductal grey (brainstem)

“Locked-In’ SyndromeInfarction of basis pontis (all descending

motor fibers to body and face)May spare eye-movementsOften spares eye-openingEEG is normal or shows alpha activity

CatatoniaSymptom complex associated with severe

psychiatric disease with:stupor, excitement, mutism, posturingcan also be seen in organic brain diease:

encephalitis, toxic and drug-induced psychosis

Conversion reactionsFairly rareOcculocephalics may or may not be presentThe presence of nystagmus with cold water

calorics indicates the patient is physiologically awake

EEG used to confirm normal activity

Glasgow Coma Scale 3-15

Eye OpeningNever 1To pain 2To verbal 3Spontaneous 4

Best Verbal ResponseNone 1Sounds 2Inapp words 3disoriented 4oriented 5

Best Motor ResponseNone 1Extensor 2Flexor Posture 3Withdrawal 4Localization 5obeys 6

Infectious Etiology

- History

- Fever

- Nuchal rigidity

- Kernigs, Brudzinski

- Rash

Examination of the Comatose Patient

HistoryOnsetRecent complaintsRecent InjuryPrior IllnessMedications

General ExamV.S.Trauma?Illness?Dugs?Nuchal Rigidity

Neurologic ExamVerbal responses oriented speech confused conversation inappropriate speech incomprehensible speech no speech

Eye opening spontaneous verbal response noxious response none

Pupillary reactions present absent

Spont eye movts orienting roving misc none

Oculocephalic responses normal

full minimal none

Oculovestibular responses normal tonic conj dysconj none

Corneal responses present absent

Repiratory pattern regular periodic ataxic

Motor responses obeys localizes w/d abnormal flexion abnormal extension none

DTR’sNormal, incr, decr

ToneNorm, para, flex, ext, flaccid

Pupillary Responses in Various Lesions

Oculocephalic and Vestibular Responses

Abnormal Breathing Patterns

Cheyne-Stokes crescendo/decrescendo pattern mixed with apnea bilateral hemisphere dysfunction

Central neurogenic hyperventilation rapid deep breathing lesion between midbrain and pons

Apneustic breathing prolonged inspiration followed by apnea pontine dysfunction

Ataxic breathing irregular pattern medullary dysfunction-close to death

Coma with hyperventilation metabolic derangement

Coma with hypoventilation drug overdose COPD

Nutritional TherapyAsses nutritional status in coma patientto help the patient to attain or maintain a

sufficient intake of energy and nutrients; therefore,

reducing the risk of adverse outcomes associated with poor nutrition

and promoting an optimal health level

Terapi supportifJalan nafas

Dilihat : Agitasi : kesan hipoksemia Gerakan nafas : dada Retraksi interkostal, dinding perut & sub kosta klavikula

Didengar suara tambahan: mendengkur, sumbatan jalan nafas

Diraba : Getaran ekspirasi Getaran di leher Fraktur mandibuler

Yang menyebabkan gangguan jalan nafasAlat yang dipakai

Perhatikan aliran darah Perfusi : periferGinjal : produksi urineNadi : ritme, rate, pengisianTekanan darah

Diusahakan : Hemodinamik stabil Kondisi tensi normal Dihindari : Hipertensi/meninggi, shock Jenis Shock : hipovolemik, kardiogenik, sepsis,

penimbunan vena perifer (polling darah)

Cairan TubuhCegah hidrasi berlebihanCairan hipotonik, hipoprotein & lama pakai

ventilator mudah terjadi hidrasiTekanan osmotik dipertahankan dengan

albuminHindari Hiponatremia

Gas darah & Keseimbangan Asam BasaAlat bantu Oksimeter untuk mengetahui

oksigenasi diusahakan Sa O2 > 95 dan Pa O2> 80 mg (dengan analisis gas darah)

PO2 dibuat sampai 100 – 150 mmHg dengan cara diberi O2

PaCO2 : 25 – 35 mm dengan hiperventilasi

Pasang Naso Gastric TubePengeluaran isi lambung berguna :

Mencegah aspirasi, intoksikasiNutrisi parenteral

Posisi & Katheter UrineHindari posisi TrendelenbergPosisi kepala 30 derajat lebih tinggiPada Koma yang lama dihindari :

DekubitusVena dalam trombosis (DVT) : pakai stocking

KATETERKateterisasi untuk memudahkan penghitungan

balans cairan

Terapi KausatifInfeksi?Perdarahan?Tumor?Metabolik?AVM?Aneurisma?

AnamnesisApakah ditanyakan onset & perjalanan penyakitnya?Apakah ditanyakan faktor risiko penyakitnya &

penyakit-penyakit yang berhubungan dengan penyakit sekarang?

Apakah ditanyakan symptom & sign?Apakah ditanyakan riwayat penyakit dahulu?Apakah ditanyakan riwayat minum obat, alkohol,

napza atau keracunan sebelumnya?Apakah ditanyakan riwayat operasi, penyinaran,

atau tindakan manajemen lain sebelumny(pengobatan alternatif)