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COMA
APPROACH , CAUSES AND EXAMINATION (INTRODUCTION)
APPROACH TO THE CASE
• FIRST ABCTHEN O2, IV ACCESS (DRAW BLOOD SAMPLE)
• IF HYPOGLYCEMIA 50% DEXTROSE
• ALWAYS EXCLUSE CERVICAL SPINE INJURY
• THEN FURTHER HISTORY AND ASSESSMENT
GLASGOW COMA SCALE
• COMPONENTS– EYE RESPONSE– VERBAL RESPONSE– MOTOR RESPONSE
GCS – EYE RESPONSE
• EYE RESPONSE4- spontaneous opening3- opening to speech2- opening to pain1- NONE
GCS – VERBAL SCORE• 5- ORIENTED• 4- CONFUSED• 3 – INAPPROPRIATE• 2- INCOMPREHENSIBLE WORDS• 1 – NONE
• VT – USED IN INTUBATED PATIENTS, MAKES THE ASSESSMENT BY GCS SCORE LESS EFFICIENT ( SO, IT RISES THE “”FOUR”” SCORE- FULL OUTLINE OF UNRESPONSIVENESS)
GCS – MOTOR SCORE
• 6- OBEYING COMMANDS• 5 – LOCALISING PAIN• 4 – WITHDRAWL TO PAIN• 3 – DECORTICATE• 2 – DECEREBRATE• 1 - NONE
FOUR SCORE
• FULL OUTLINE OF UNRESPONSIVENESS
• COMPONENTS• EYE RESPONSE• MOTOR RESPONSE• BRAIN STEM REFLEXES• BREATHING PATTERN
FOUR SCORE - BREATHINGPATTERN
• 4 – NOT INTUBATED , REGULAR BREATHING • 3 – NOT INTUBATED, CHEYNES STOKES
BREATHING• 2 – NOT INTUBATED, IRREGULAR BREATHING• 1 - INTUBATED, BREATHES ABOVE
VENTILATOR RATE• 0 – INTUBATED, BREATH BY VENTILATOR OR
APNEA
FOUR SCORE – BRAIN STEM REFLEXES
• 4 – PUPIL AND CORNEAL REFLEXES +• 3 – ONE PUPIL WIDE AND FIXED• 2 – PUPIL OR CORNEAL REFLEXES ABSENT• 1 – PUPIL AND CORNEAL REFLEX ABSENT• 0 – PUPIL, CORNEAL AND COUGH REFLEX
ABSENT
FOUR SCORE – EYE COMPONENTS
• EYE COMPONENTS• 4 – OPENING OR OPENED TRACKING TO
COMMENTS• 3 – OPENED NOT TRACKING• 2 – OPENS TO LOUD VOICE• 1 – OPENS TO PAIN• 0 – EYES CLOSED EVEN AFTER PAIN
FOUR SCORE – MOTOR COMPONENTS
• 4 – THUMBS UP, FIST SIGN• 3 – LOCALISING TO PAIN• 2 – FLEXION RESPONSE TO PAIN• 1 – EXTENSION RESPONSE TO PAIN• 0 – NO RESPONSE TO PAIN
FOUR SCORE
• WAS DEVELOPED IN MAYO CLINIC
• IT HAS GOOD SENSITIVITY , SPECIFITY SCORES
• SINCE IN INTUBATED PATIENTS, CLINICAL JUDGEMENT BY GCS SCORE IS DIFFICULT.. ON THESE SITUATIONS IT CAN BE USED
causes
• Metabolic– DM– HEPATIC FAILURE– RENAL FAILURE– HYPOTHERMIA– HYPOTHYROIDISM– RESPIRATORY FAILURE– HYPOXIC ENCEPHALOPATHY– HYPOGLYCEMIA
• DRUGS
– LOOK FOR PUPIL• MOSTLY ARE SYMPATHETIC DRUGS, SO THERE WILL BE
DILATED PUPILS ON ITS USAGE
STRUCTURAL CAUSES OF COMA
• MENINGITIS• ENCEPHALITIS• SAH• EPILEPSY• HEAD INJURY• HYPERTENSIVE ENCEPHALITIS
LOCALISED LESION
• IT CAN BE• SUPRATENTORIAL LESION– CAUSES DAMAGE TO DEEP DIENCEPHALIC STRUCTURE
• SUBTENTORIAL LESION
– CAUSE DAMAGE TO BRAINSTEM
SUPRATENTORIAL LESION
• CEREBRAL HEMORRHAGE• CEREBRAL INFARCTION WITH EDEMA• SUBDURAL HEMATOMA– Can be acute/subacute/chronic• Gradual decline in consciousness
SUPRATENTORIAL LESION
• TUMOUR• CEREBRAL ABSCESS• PITUITARY APOPLEXY
SUBTENTORIAL LESION
• CEREBELLAR HEMORRHAGE• PONTINE HEMORRHAGE• BRAIN STEM INFARCTION• TUMOUR• CEREBELLAR ABSCESS• SECONDARY EFFECTS OF TRANSTENTORIAL
HERNIATION OF BRAIN DUE TO CEREBRAL MASS LESION
HISTORY ALWAYS IMPORTANT
• IT CAN BE• ACUTE• SUBACUTE• CHRONIC
ACUTE ONSET
• TRAUMA
• If there is lucid interval – highly suggestive of EDH
• TRAUMA WITH CONCUSSION FOLLOWED BY FEW DAYS LATER BY FLUCTUATING DROWSINESS AND STUPOR
• HISTORY OF HEADACHE BEFORE COMA- MAY SIGNIFIES THERE MAY BE TUMOUR
HISTORY OF SEIZURES
• IT MAY INDICATE EITHER– Encephalitis– Meningitis– Abscess– Tumours
History of drug abuse
• There will be a traces in the surrounding
PSYCHOLOGICAL COMA
• RARE
EXAMINATION OF COMA PATIENT
• PATIENT APPEARANCE BUILT, CLEANLINESS, ALCOHOL SMELL+/-
ANY SIGN OF EXTERNAL INJURY
INJURIES IN HEAD?????
BASIC NEUROLOGICAL EXAMINATION
• ASSESS LEVEL OF CONSCIOUSNESS BY GCS SCOE
• LOOK FOR SIGNS OF HEAD INJURY
• SPLINT THE NECK, UNTIL CERVICAL SPINE INJURY EXCLUDED
• IF THERE IS NO NECK INJURY (( BY CLINICAL AND RADIOLOGICAL ) CHECK FOR NECK STIFFNESS
• CHECK PUPIL SIZES
• NORMAL PUPIL SIZE – 2 – 6 MM
• PIN POINT PUPIL - <1 MM– PONTINE HEMORRHAGE– MORPHINE/HEROIN
• SMALL PUPIL (1-2.5MM)
– METABOLIC ENCEPHALOPATHY– DAMAGE TO SYMPATHETIC PATHWAY IN
HYPOTHALAMUS
• ONE SIDE PUPIL DILATED AND FIXED AND OTHER SIDE PUPIL NORMAL– WARNING :: TEMPORAL LOBE HERNIATION AND
PRESSING ON THE OCULOMOTOR NERVE
• LARGER PUPILS– MAY DUE TO ATROPINE LIKKE DRUGS
– LSD– AMPHETAMINE– COCAINE• As these are sympathomimetics
If there is head injury• If there is head injury
• Follow the nice guidelines for CT HEAD– GCS <13/15– GCS <15 AFTER 2 HOURS OF INJURY– PERSISTENT VOMITTING– OLD AGE– ON ANTICOAGULANTS– FND– POST –TRAUMATIC SEIZURE– SUSPECTED OPEN OR DEPRESSED FRACTURE
• SKULL XRAYS THOUGH IT SERVES NO DIAGNOSTIC USE IN ADULTS, IT IS COMMONLY USED IN CHILDREN
IF THERE IS A BLEED ON CT SCAN
• MANAGEMENT BASED ON VOLUME OF THE BLEED AND MIDLINE SHIFT IN MM ONLY, IRRESPECTIVE OF GCS
• SDH >10MM3 AND MIDLINE SHIFT >5 MM – SURGERY
• EDH >30CM3 – SURGERY• ICH, CONTUSION ->50CM3 - SURGERY
• MAINTAINING THE CEREBRAL PERFUSION PRESSURE IS IMPORTANT..
• AS FALL IN PRESSURE BELOW THIS WORSEN THE NEUROLOGICAL STATUS.
• ALSO REMEMBER, THE AMOUNT OF BLOOD NEEDED BY GREY AND WHITE MATTER IS DIFFERENT
• GREY MATTER – 100ML/G/MIN• WHITE MATTER – 20 ML /G/MIN
• COMA WITHOUT FOCAL NEUROLOGICAL SIGN AND NECK STIFFNESS AND NORMAL DOLL EYE RESPONSE – MOSTLY METABOLIC
• COMA WITH NECKSTIFFNESS – CAUSES
• SAH• ENCEPHALITIS• ICH• CEREBRAL MALARIA
DOLL EYE RESPONSE(VESTIBULO – OCULAR REFLEX)
• REFLEX CAN BE TESTED BY RAPID HEAD IMPULSE TEST OR HALMAGYI-CURTHOYS TEST
VOR
• IF U MOVE THE HEAD IN ANY DIRECTION, IF THE VESTIBULO OCULO SYSTEM IS INTACT, IT HELP TO KEEP THE EYE IN NEUTRAL POSITION
VESTIBULO OCULAR REFLEX AND DRUG INDUCED COMA
• IN MOST CASES OF DRUG INDUCED COMA, THE VESTIBULO OCULAR REFLEX IS INTACT
CALORIC RESPONSE TEST
• WARM WATER (44 DEGREE C)
• COLD WATER ( 30 DEGREE C)
COWS
• COLD – OPPOSITE ( FAST COMPONENT)
• WARM – SAME SIDE (FAST COMPONENT)
•CALORIC RESPONSE ALSO TEST THE INTACTNESS OF VESTIBULO – OCULAR REFLEX
THANK U
• NEXT PPT – WILL BE LOCALISING THE LESION IN COMA