MANAGEMENT OF MANAGEMENT OF UNCONSCIOUS UNCONSCIOUS

PATIENTPATIENT

DR. B. PRAKASH.DR. B. PRAKASH.Prof. M.B. PRANESHProf. M.B. PRANESH

DEPT. OF NEUROLOGYDEPT. OF NEUROLOGYKG HOSPITAL AND POSTGRADUATE KG HOSPITAL AND POSTGRADUATE

INSTITUTE, INSTITUTE, COIMBATORE – INDIACOIMBATORE – INDIA

INTRODUCTIONINTRODUCTION

Unconscious patient makes everybody Unconscious patient makes everybody

anxiousanxious

Requires structured way of approachRequires structured way of approach

Should act Urgently / Appropriately / Should act Urgently / Appropriately /

AccuratelyAccurately

Conscious> Drowsy> Unconscious> ?Conscious> Drowsy> Unconscious> ?

Death / Permanent Brain DamageDeath / Permanent Brain Damage

STAGES OF CONSCIOUSNESSSTAGES OF CONSCIOUSNESSConscious: Awareness of self and surroundings.Conscious: Awareness of self and surroundings.Clouding of Consciousness: Reduced attention Clouding of Consciousness: Reduced attention span with irritability.span with irritability.Confusion: Mild lowering of consciousness.Confusion: Mild lowering of consciousness.Lethargy : Drowsy but arousable.Lethargy : Drowsy but arousable.Obtundation: Drowsy, slow reaction, gives Obtundation: Drowsy, slow reaction, gives appropriate answers, back asleep on leaving appropriate answers, back asleep on leaving alone.alone.Stupor: Roused by vigorous repetitive stimuli, Stupor: Roused by vigorous repetitive stimuli, moans without proper answering.moans without proper answering.Light coma: Unarousable, disorganized primitive Light coma: Unarousable, disorganized primitive motor responses.motor responses.Deep Coma: Absence of response to most painful Deep Coma: Absence of response to most painful stimuli.stimuli.

Eye opening 4 Spontaneous3 To speech2 To pain1 NoneBest motor response6 Obeying5 Localizing pain4 Withdrawal3 Abnormal flexing2 Extensor response1 None

GLASGOW COMA SCALE

Best verbal response 5 Oriented4 Confused conversation3 Inappropriate words2 Incomprehensible sounds1 None

USED MOSTLY FOR HEAD INJURY

PATIENTS RATHER THAN STROKE

(HEMIPLEGIA,APHASIA)

AlgorhythmAlgorhythmCOMA

Airway/?IntubateIV LineCFCDTests-EmeHistory-Eme

CBC, ESRSugar,RFTABG,LytesCXR,ECGCa,Mg,Toxic Scr’n

TRAUMA

CT Scan

No Trauma

Neu.Surg

Stiff Neck CT Scan

Normal SAH

LP

Meningitis

Toxin

Alc->Thiamine 100mg / 50% Dextose 50 ml

Opiate -> Inj.Naloxone 0.4-0.8mg IV

BenzDia ->Inj.Flumazenil 0.2-1 mg IV

Others -> Stomach wash / Antidote / Sympt

Supple

CNS Exam

Normal Lateralising

Metabolic CT Scan

SELECTIVE HISTORY TAKINGSELECTIVE HISTORY TAKING

Friend /Relative /ObserverFriend /Relative /Observer

When was he Last seen?When was he Last seen?

How was he discovered?How was he discovered?

What is the mode & What is the mode &

evolution of Coma ?evolution of Coma ?

What are the past Illness?What are the past Illness?

What drugs he is on?What drugs he is on?

Is any past mental history?Is any past mental history?

TraumaTrauma

Drug / ToxinsDrug / Toxins

Head acheHead ache

VomitingVomiting

Seizures Seizures

GiddinessGiddiness

FeverFever

Chest painChest pain

SELECTIVE EXAMINATIONSELECTIVE EXAMINATION

VITAL SIGNS:VITAL SIGNS:

HTN – Structural /HT.EHTN – Structural /HT.E

Hypo – ShockHypo – Shock

SKINSKIN::

Trauma / Needle MarksTrauma / Needle Marks

Rashes / Cherry rednessRashes / Cherry redness

JaundiceJaundice

BREATH:BREATH:

Alcohol /AcetoneAlcohol /Acetone

Fetor HepaticusFetor Hepaticus

HEADHEAD

Hematoma/#/Lacer’nsHematoma/#/Lacer’ns

ENT:ENT:

CSF otorrhea/RhinorrheaCSF otorrhea/Rhinorrhea

HemotympanumHemotympanum

Tongue BitingTongue Biting

NECK:NECK:

Do not Move if injuredDo not Move if injured

Neck Stiffness Neck Stiffness (Meningitis / SAH)(Meningitis / SAH)

Gen. Phy. ExamGen. Phy. ExamFever: Syst infection / Meningitis / EncephalitisFever: Syst infection / Meningitis / Encephalitis

Hyperthermia: Heat stroke / Anticholinergic intoxcn.Hyperthermia: Heat stroke / Anticholinergic intoxcn.

Hypothermia : Cold exp / Alcohol / Barb /Phenoth’zHypothermia : Cold exp / Alcohol / Barb /Phenoth’z

Sedative/ HypoSedative/ HypoGlycemia/ HypoThyroid/ Per.cir.FailGlycemia/ HypoThyroid/ Per.cir.Fail

Tachypnea : Acidosis / PneumoniaTachypnea : Acidosis / Pneumonia

Aberrant Respiratory Patterns: BS disordersAberrant Respiratory Patterns: BS disorders

Marked HTN : HT.E / SAH / ICP / Head injuryMarked HTN : HT.E / SAH / ICP / Head injury

Hypotension : Alcohol / Barb / Int.bleed / AMI / Hypotension : Alcohol / Barb / Int.bleed / AMI / Sepsis / HypoThyroidism / Addison’s crisisSepsis / HypoThyroidism / Addison’s crisis

Petechiae: TTP/ Meningococcemia/ Bld’g DiathesisPetechiae: TTP/ Meningococcemia/ Bld’g Diathesis

NEUROLOGIC EXAMINATIONNEUROLOGIC EXAMINATION

1. Gen. Appearance1. Gen. Appearance

2. Level of Cons’ss2. Level of Cons’ss

3. Respiration3. Respiration

4. Fields4. Fields

5. Fundi5. Fundi

6. Corneal Reflex6. Corneal Reflex

1. To asses the Depth of COMA

2. To localize/Lateralize the lesion

7.Gag Reflex7.Gag Reflex

8.Pupils8.Pupils

9.Ocular Movements9.Ocular Movements

10.Motor Response10.Motor Response

11.Sensory Resp’se11.Sensory Resp’se

12.Reflexes12.Reflexes

NEU.EXAM-1.GEN.APPEAR’CENEU.EXAM-1.GEN.APPEAR’CE

Open Eyelids / Slack Jaw – Deep ComaOpen Eyelids / Slack Jaw – Deep Coma

Head & Gaze deviation – Ipsi.Hemi.LesionHead & Gaze deviation – Ipsi.Hemi.Lesion

Myoclonus –BS Lesion / MetabolicMyoclonus –BS Lesion / Metabolic

Focal Seizures – Contra.Lesion / HyperglycemiaFocal Seizures – Contra.Lesion / Hyperglycemia

NEU.EXAM- 2.LEVEL OF CONS.NEU.EXAM- 2.LEVEL OF CONS.

Document the response to specific StimulusDocument the response to specific Stimulus

Quantify with Glasgow Coma ScaleQuantify with Glasgow Coma Scale

NEU.EXAM- 3.RESPIRATION.NEU.EXAM- 3.RESPIRATION.Depressed – Any deep ComaDepressed – Any deep ComaChyne-stokes – Bihemisp / MetabolicChyne-stokes – Bihemisp / MetabolicHypervent’n – Met.Aci/ Hep.Enc/ BS les/ Coning Hypervent’n – Met.Aci/ Hep.Enc/ BS les/ Coning Apneustic – Pontine DamageApneustic – Pontine DamageCluster – Pontine/ Cerebellar damageCluster – Pontine/ Cerebellar damageAtaxic (Biot’s) – Medullary LesionAtaxic (Biot’s) – Medullary Lesion

NEUROLOGIC EXAMINATIONNEUROLOGIC EXAMINATION

4.Fields – By Menace Reflex4.Fields – By Menace Reflex5.Fundii –Papilledema - >12 hrs of 5.Fundii –Papilledema - >12 hrs of ↑ ICT↑ ICT Subhyloid H’ge – Asst’d č SAHSubhyloid H’ge – Asst’d č SAH6.Corneal Reflex – Aff: CrV / Eff: CrVII6.Corneal Reflex – Aff: CrV / Eff: CrVII7.Gag Reflex – Absent in BS Les / Deep coma7.Gag Reflex – Absent in BS Les / Deep coma11.Sensory Response – Lateralizing Sensory 11.Sensory Response – Lateralizing Sensory

LossLoss12.Deep T.Reflex – Helps in Lateralizing12.Deep T.Reflex – Helps in Lateralizing13.Plantar Reflex -- Helps in Lateralizing13.Plantar Reflex -- Helps in Lateralizing -- -- ↑ ↑↑ ↑ Structural / Metabolic Structural / Metabolic

1.1. Symmetrical Reacting pupils – intact midbrainSymmetrical Reacting pupils – intact midbrain

2.2. Normal pupils + Absent Dolls – Metabolic / Sedatives Normal pupils + Absent Dolls – Metabolic / Sedatives

3.3. Fixed Mid position pupil – Focal Midbrain LesionFixed Mid position pupil – Focal Midbrain Lesion

4.4. Pinpoint Reactive – Pontine Damage / Opiate / OPC / Pinpoint Reactive – Pontine Damage / Opiate / OPC / Hydrocephalus / Thalamic Hemorrhage Hydrocephalus / Thalamic Hemorrhage

5.5. Unil / Dil / Fixed – Uncal Herniation - same/oppositeUnil / Dil / Fixed – Uncal Herniation - same/opposite

6.6. Bil / Dil / Fixed – Central Herniation / Hypoxia / Atropine Bil / Dil / Fixed – Central Herniation / Hypoxia / Atropine or Barbiturate Poisoning / Mydriaticsor Barbiturate Poisoning / Mydriatics

7.7. Eccentric oval - Early midbrain / III n CompressionEccentric oval - Early midbrain / III n Compression

8.8. Unil / Small (Horner) – Large Cerebral Hemorrhage Unil / Small (Horner) – Large Cerebral Hemorrhage Affecting ThalamusAffecting Thalamus

NEU.EXAM- 8.PUPILS.NEU.EXAM- 8.PUPILS.

Frontal Eye fields drive horiz. Gaze to opp.sideFrontal Eye fields drive horiz. Gaze to opp.side

Pontine Gaze Centres drive gaze to same sidePontine Gaze Centres drive gaze to same side

Midbrain tegmentum & Lower diencephalon Midbrain tegmentum & Lower diencephalon mediates vertical gaze movementsmediates vertical gaze movements

Oculocephalic & Oculovestibular Reflexes act Oculocephalic & Oculovestibular Reflexes act via semicircular canals / CrVIII / Vestibular and via semicircular canals / CrVIII / Vestibular and 3,4&63,4&6thth N Nuclei -- in eliciting gaze movements N Nuclei -- in eliciting gaze movements in comatose patientsin comatose patients

Normal gaze indicate Intact Cr III – VIII (MB & Normal gaze indicate Intact Cr III – VIII (MB & PONS)PONS)

NEU.EXAM- 9.Ocular Movements.NEU.EXAM- 9.Ocular Movements.

(A) POSITION OF THE EYES AT REST :(A) POSITION OF THE EYES AT REST :1.1. Gaze away from Hemi paresis – Contra lateral Hemispherical lesionGaze away from Hemi paresis – Contra lateral Hemispherical lesion

2.2. Gaze towards Hemi paresis – Contra lateral Pontine Lesion / Contra Gaze towards Hemi paresis – Contra lateral Pontine Lesion / Contra lateral Seizure Activity lateral Seizure Activity

3.3. Forced down gaze – Mid Brain Tectal / Thalamic LesionForced down gaze – Mid Brain Tectal / Thalamic Lesion

4.4. Slow roving gaze – Bihemisperical LesionSlow roving gaze – Bihemisperical Lesion

5.5. Ocular bob (Slow upward Brisk Downward & Loss of Horizontal eye Ocular bob (Slow upward Brisk Downward & Loss of Horizontal eye movements) – Bil. Pontine gaze centre dysfunction movements) – Bil. Pontine gaze centre dysfunction

6.6. Ocular Dip ( Slow Arrhythmic Downward And fast Upward eye Ocular Dip ( Slow Arrhythmic Downward And fast Upward eye movement with normal Dolls) – Diffuse cortical Axonal Damagemovement with normal Dolls) – Diffuse cortical Axonal Damage

7.7. Saccadic (Fast) movements in Coma – PsychologicalSaccadic (Fast) movements in Coma – Psychological

8.8. Horizontal divergent eyes – DrowsinessHorizontal divergent eyes – Drowsiness

9.9. Bilateral Abducted eyes – 3Bilateral Abducted eyes – 3rdrd N Dysfunction N Dysfunction

10.10. Bilateral Adducted eyes – 6Bilateral Adducted eyes – 6thth N Dysfunction (ICP) N Dysfunction (ICP)

NEU.EXAM- 9.Ocular Movements.NEU.EXAM- 9.Ocular Movements.

(B)OCULOCEPHALIC (DOLLS) REFLEX :(B)OCULOCEPHALIC (DOLLS) REFLEX :

Turn the head briskly side to side – Conjugate Turn the head briskly side to side – Conjugate

opposite eye movements are normal (Could opposite eye movements are normal (Could

not be elicited in normal persons due to not be elicited in normal persons due to

supranuclear control)supranuclear control)

Normal reflex in coma indicates Normal reflex in coma indicates

bihemispherical / metabolic abnormality bihemispherical / metabolic abnormality

Absent dolls due to (upper) brainstem lesionAbsent dolls due to (upper) brainstem lesion

NEU.EXAM- 9.Ocular Movements.NEU.EXAM- 9.Ocular Movements.

(C) OCULOVESTIBULAR (CALORIC) REFLEX :(C) OCULOVESTIBULAR (CALORIC) REFLEX :

Flex the Head 30Flex the Head 30° -- Lavage the ear with cold ° -- Lavage the ear with cold

((3030°C) water -30 ml – Observe for 30 sec – Opp. °C) water -30 ml – Observe for 30 sec – Opp.

Side Nystagmus is normal response (COWS) – Side Nystagmus is normal response (COWS) –

Tonic Eye deviation to same sideTonic Eye deviation to same side

No Nystagmus but normal tonic phase – No Nystagmus but normal tonic phase –

Bihemispherical Bihemispherical

Absent Response – Deep Coma / BS dysfunctionAbsent Response – Deep Coma / BS dysfunction

Asymmetric Response – BS lesionAsymmetric Response – BS lesion

Conjugate gaze paresis -- Hemispherical / Pontine Conjugate gaze paresis -- Hemispherical / Pontine

NEU.EXAM- 9.Ocular Movements.NEU.EXAM- 9.Ocular Movements.

NEU.EXAM–MOTOR RESPONSESNEU.EXAM–MOTOR RESPONSES

Best indicator for the severity of comaBest indicator for the severity of coma

Observe Spontaneous movements for symmetry Observe Spontaneous movements for symmetry

and purposeand purpose

Check tone for symmetry / Bil LL Check tone for symmetry / Bil LL ↑ tone favors ↑ tone favors

Herniation.Herniation.

Induce increasing stimuli & observe symmetryInduce increasing stimuli & observe symmetry

1. Verbal command -(open eyes, Show 2 fingers)1. Verbal command -(open eyes, Show 2 fingers)

2.Sternal rub / pressure- (Purposeful / Gross 2.Sternal rub / pressure- (Purposeful / Gross

localizing responses)localizing responses)

3.Nailbed Pressure :3.Nailbed Pressure :

a) Withdrawl – Motor cortexa) Withdrawl – Motor cortex

b) Decortication (Flexion of the Elbow & wrist with b) Decortication (Flexion of the Elbow & wrist with

supination of the arm)– Deep Hemisphere / Upper supination of the arm)– Deep Hemisphere / Upper

midbrain level inv of pyramidal tract midbrain level inv of pyramidal tract

c) Decerebration (Extension of Elbows Wrist & c) Decerebration (Extension of Elbows Wrist &

Pronation) – Pons / Upper medullary lesionPronation) – Pons / Upper medullary lesion

NEU.EXAM–MOTOR RESPONSESNEU.EXAM–MOTOR RESPONSES

DIAGNOSTIC TESTINGDIAGNOSTIC TESTING1. Head CT (or MRI) Scan :1. Head CT (or MRI) Scan :

Great boon for the Diagnosis of structural lesions.Great boon for the Diagnosis of structural lesions.

Mostly CT is enough & is Quick for the Patient & Doctor.Mostly CT is enough & is Quick for the Patient & Doctor.

All types of ICH, Tumor & Hydrocephalus.All types of ICH, Tumor & Hydrocephalus.

Bihemispherical Infarcts, BS lesion, DAI, Meningitis, Encephalitis, Bihemispherical Infarcts, BS lesion, DAI, Meningitis, Encephalitis,

isodense SDH & CVT may be missed by CT Scan.isodense SDH & CVT may be missed by CT Scan.

Contrast when required / Bone window - TraumaContrast when required / Bone window - Trauma

2. Lumbar Puncture :2. Lumbar Puncture :

Exclude ICT / Mass effect by CT Scan Before LPExclude ICT / Mass effect by CT Scan Before LP

To Diagnose Meningitis /Encephalitis / SAHTo Diagnose Meningitis /Encephalitis / SAH

Do not postpone Treatment for Men’s if LP is delayedDo not postpone Treatment for Men’s if LP is delayed

3. EEG:3. EEG:

1. Progressively increasing background slowing

corresponds to the level of consciousness.

2. Triphasic waves in hepatic (other) Encephalopathies.

3. Asymmetric slowing in hemispherical lesion.

4. Alpha coma : Alpha waves all over – pontine / Diff.Cort

5. Excessive Beta waves in Sedative Intoxication.

6. Electrical Status in Non-Convulsive SE.

7. Normal Alpha Activity seen in Locked in syndrome &

Hysteria.

DIAGNOSTIC TESTINGDIAGNOSTIC TESTING

EMERGENCY TREATMENT FOR COMAEMERGENCY TREATMENT FOR COMA

1. ICSOL: Surgical intervention1. ICSOL: Surgical intervention

2. INCREASED ICP (For buying time):2. INCREASED ICP (For buying time):

a. Head Elevationa. Head Elevation

b. Intubation / Hyperventilationb. Intubation / Hyperventilation

c. Sedation if Agitated (midazolam) c. Sedation if Agitated (midazolam)

d. 20% Mannitol 1gm/kg d. 20% Mannitol 1gm/kg

e. Dexamethasone 10mg IV Q6H e. Dexamethasone 10mg IV Q6H

3. ENCEPHALITIS (HSE): 3. ENCEPHALITIS (HSE): Acyclovir 10mg/kg IV Q8HAcyclovir 10mg/kg IV Q8H

4. MENINGITIS : Ceftriaxone +Ampicillin4. MENINGITIS : Ceftriaxone +Ampicillin

CAUSES OF STUPOR AND COMACAUSES OF STUPOR AND COMA1. STRUCTURAL1. STRUCTURAL a)Traumaa)Trauma

i.ICHi.ICH

ii.Diff Axon Injuryii.Diff Axon Injury

iii.Concussioniii.Concussion

b)CVAb)CVA

i.ICH / SAHi.ICH / SAH

ii.Hemisp / BS Infii.Hemisp / BS Inf

iii.CVTiii.CVT

iv.HTN’ve Encep’thyiv.HTN’ve Encep’thy

c)Infectionc)Infection

i.Meningitisi.Meningitis

ii.Encephalitisii.Encephalitis

iii.Abscessiii.Abscess

d)Inflammatoryd)Inflammatory

i.Autoimmune Vasculitisi.Autoimmune Vasculitis

ii.Demyelinationii.Demyelination

e)Neoplasme)Neoplasm

f)Hydrocephalus f)Hydrocephalus

2. TOXIC / METABOLIC2. TOXIC / METABOLIC a)Global Hypoxia / Ischemiaa)Global Hypoxia / Ischemia

b)Elec’te / Acid-Base Disordersb)Elec’te / Acid-Base Disorders i.pH Disturbancesi.pH Disturbances ii. Hyper/Hypo Natremiaii. Hyper/Hypo Natremia iii. Hyper/Hypo Glycemiaiii. Hyper/Hypo Glycemia iv. Hyper/Hypo Calcemiaiv. Hyper/Hypo Calcemia c)Drug intoxic’n / Withdrawlc)Drug intoxic’n / Withdrawl d)Temp’re (Hyper/Hypo thermia)d)Temp’re (Hyper/Hypo thermia) e)Organ System Dysfunctione)Organ System Dysfunction i.Liveri.Liver ii.Kidneyii.Kidney iii.Thyroidiii.Thyroid iv.Adrenaliv.Adrenal v.Cardiac /Respiratoryv.Cardiac /Respiratory f)Seizures and Post-ictal states f)Seizures and Post-ictal states g)Thiamine / B12 Deficiencyg)Thiamine / B12 Deficiency

3. PSYCOGENIC COMA3. PSYCOGENIC COMA

CEREBRO VASCULAR ACCIDENTCEREBRO VASCULAR ACCIDENT

10% of coma are due to CVA10% of coma are due to CVA

Variable depth of coma with HemiplegiaVariable depth of coma with Hemiplegia

Large infarct / ICH -Facial / Limb WeaknessLarge infarct / ICH -Facial / Limb Weakness

IVH -Decerebration / MeningismusIVH -Decerebration / Meningismus

Brain Stem Infarct - BS SignsBrain Stem Infarct - BS Signs

VBI - Loss of Bl.Supply to RAS - Drop attackVBI - Loss of Bl.Supply to RAS - Drop attack

SAH - Th’rclap HA , Mening’s , Focal deficitsSAH - Th’rclap HA , Mening’s , Focal deficits

HT.E - Blindness,Fits,Paps,Retino/Nephro’yHT.E - Blindness,Fits,Paps,Retino/Nephro’y

CVT-Fits,HA,ICT,Mening’s,Focal DeficitsCVT-Fits,HA,ICT,Mening’s,Focal Deficits

Small vessel occl’n-SLE,SBE,DIC,TTPSmall vessel occl’n-SLE,SBE,DIC,TTP

Ischemic Gliosis of PonsIschemic Gliosis of Pons

SLESLE

Pontine InfarctPontine Infarct

Intra Cerebral HemorrhageIntra Cerebral Hemorrhage

ANEURYSM & SAHANEURYSM & SAH

10 / 1,00,000 PER YEAR10 / 1,00,000 PER YEAR Frequently in femalesFrequently in females Age, HTN, Smoking, Alcohol –riskAge, HTN, Smoking, Alcohol –risk 70% gets Warning leaks70% gets Warning leaks 45% Manifest as COMA at the onset45% Manifest as COMA at the onset Suspicion, CT & LP are Diagnostic methodsSuspicion, CT & LP are Diagnostic methods MRA, CT Angio & DSA for confirmationMRA, CT Angio & DSA for confirmation Close monitor’g, rest, sedate, Vol.expaners, AED, Close monitor’g, rest, sedate, Vol.expaners, AED, Avoid Vasospasm, Anti HTN, & DulcolaxAvoid Vasospasm, Anti HTN, & Dulcolax Plan Surgery at the earliest Plan Surgery at the earliest

AneurysmsAneurysms

13% of coma are due to trauma13% of coma are due to trauma

History & Evidences of external InjuryHistory & Evidences of external Injury

Concussion – Immediate / Late ComaConcussion – Immediate / Late Coma

Contusion / Laceration – Foc.def / Seiz’sContusion / Laceration – Foc.def / Seiz’s

EDH (MMA H’ge) - Lucid Interval EDH (MMA H’ge) - Lucid Interval

SDH – Delayed SymptomsSDH – Delayed Symptoms

Monitor T,P,BP,ICP,CT, MRI,C.Spine for Monitor T,P,BP,ICP,CT, MRI,C.Spine for all Trauma.all Trauma.

TRAUMATRAUMA

Contusion / Concussion / DAI / SAHContusion / Concussion / DAI / SAH

Common Cause of ComaCommon Cause of Coma

Flushed face, Conj.inj., Bounding pulse, Dil’d pp,Flushed face, Conj.inj., Bounding pulse, Dil’d pp,

Alcohol from Breath, Stomach & BloodAlcohol from Breath, Stomach & Blood

ICH, Trauma, SDH, Wernicke’s Encp’thyICH, Trauma, SDH, Wernicke’s Encp’thy

Urgent CT, LFT, Coag’ln profileUrgent CT, LFT, Coag’ln profile

Inj.B1 & 50% Dextrose if hypoglycemicInj.B1 & 50% Dextrose if hypoglycemic

AED if H/O seizuresAED if H/O seizures

ALCOHOL INTOXICATIONALCOHOL INTOXICATION

Tongue bite, Froath, Bloody sputum, InjuryTongue bite, Froath, Bloody sputum, Injury

Etiology of convulsion may be differentEtiology of convulsion may be different

Confusion & IrritabilityConfusion & Irritability

Brief stupor and profound sleepBrief stupor and profound sleep

To rule out Non-Convulsive Status To rule out Non-Convulsive Status

Post ictal statePost ictal state

DIABETESDIABETES

Hypo is worse so give IV dextrose Hypo is worse so give IV dextrose

Dec DTR, T, BP, Hyd’n, / Inc P, RDec DTR, T, BP, Hyd’n, / Inc P, R

Smell of AcetoneSmell of Acetone

Suicidal/ Homicidal/ AccidentalSuicidal/ Homicidal/ AccidentalDrugs and ToxinsDrugs and ToxinsHistory / Physical findingsHistory / Physical findingsLavage/ Symptomatic/ Antidote/ Tt ComplLavage/ Symptomatic/ Antidote/ Tt ComplNo Lateralizing signsNo Lateralizing signsDepth of coma Acc to Strength & AmountDepth of coma Acc to Strength & Amount

PoisoningPoisoning

MeningitisMeningitisHA, Fever, LOC, Meningismus (not in age HA, Fever, LOC, Meningismus (not in age extremes & Imm. supp), ICPextremes & Imm. supp), ICPENT infection, SBE,ENT infection, SBE,Rash in mening.meng’sRash in mening.meng’sDo CT before LPDo CT before LP

ENCEPHALITISENCEPHALITIS

Present with Fever, Meningismus, Altered Present with Fever, Meningismus, Altered sensorium, seizures and focal Deficits.sensorium, seizures and focal Deficits.Usually the Seizures are difficult to controlUsually the Seizures are difficult to controlEEG& CSF are better diagnostic tools than ImagingEEG& CSF are better diagnostic tools than ImagingHSEHSE affects FT regions asymmetrically present affects FT regions asymmetrically present with focal seizureswith focal seizuresEEG may show PLEDs, Focal epileptic activity or EEG may show PLEDs, Focal epileptic activity or slowingslowingMRI shows signal alterations in inferior FT regions MRI shows signal alterations in inferior FT regions asymmetricallyasymmetricallyIV Acyclovir is the Treatment of choice with full IV Acyclovir is the Treatment of choice with full dose AEDdose AED

Herpes Simplex EncephalitisHerpes Simplex Encephalitis

PSEUDOCOMAPSEUDOCOMA1. PSYCHOGENIC COMA1. PSYCHOGENIC COMA

Negativistic Behavior (Resists opening eye)Negativistic Behavior (Resists opening eye)Avoidance Behavior (Hand avoids face on dropping)Avoidance Behavior (Hand avoids face on dropping)Intact Saccades / Normal Caloric responseIntact Saccades / Normal Caloric responseRecovery on very painful stimuliRecovery on very painful stimuli

2. LOCKED IN SYNDROME2. LOCKED IN SYNDROMEComplete paralysis except for vertical eye movementsComplete paralysis except for vertical eye movementsPt usually alert and can communicate thru’ EOMPt usually alert and can communicate thru’ EOMDue to bilateral Pontine Damage (Infarct)Due to bilateral Pontine Damage (Infarct)

3. AKINETIC MUTISM 3. AKINETIC MUTISM (Motionless, Mindless Wakefulness)Extreme psychomotor retardation- Appears awakeExtreme psychomotor retardation- Appears awakeShow Delayed Limited responsesShow Delayed Limited responsesDue to Extensive Thalamic / Frontal DamageDue to Extensive Thalamic / Frontal Damage

VEGETATIVE STATEVEGETATIVE STATELoss of Awareness of self and surroundings.Loss of Awareness of self and surroundings.Normal sleep wake cycles & BS reflexes.Normal sleep wake cycles & BS reflexes.Normal metabolic and circulatory functions.Normal metabolic and circulatory functions.Normal eye opening / closure & Swallowing.Normal eye opening / closure & Swallowing.Eye movements & Sensory Localization – Poor.Eye movements & Sensory Localization – Poor.Doesn’t obey requ’s / No comprehensible words.Doesn’t obey requ’s / No comprehensible words.Preserved Hypothalamic & Autonomic fns.Preserved Hypothalamic & Autonomic fns.Above findings lasting > 1 month – PVS.Above findings lasting > 1 month – PVS.CVA, SAH, Trauma, Toxin, Injury, Infn, Arrest etc.,CVA, SAH, Trauma, Toxin, Injury, Infn, Arrest etc.,Low amplitude irregular Delta in EEG.Low amplitude irregular Delta in EEG.Cortical necrosis, multi-infarcts, Diffuse neuronal Cortical necrosis, multi-infarcts, Diffuse neuronal loss and gliosis of neocortex, hippocampus loss and gliosis of neocortex, hippocampus thalamus & purkinje cells – BS relatively intact.thalamus & purkinje cells – BS relatively intact.

GENERAL CARE FOR COMATOSE PTSGENERAL CARE FOR COMATOSE PTS

1.1. Protect airway / Adeq. Vent’n & O2 / NPO Protect airway / Adeq. Vent’n & O2 / NPO

2.2. Good Hydration – Prefer isotonic SalineGood Hydration – Prefer isotonic Saline

3.3. Nasogatric adeq. calorie feed with smaller tube Nasogatric adeq. calorie feed with smaller tube

4.4. Prevent Bedsore – Q2H Position / Water bedPrevent Bedsore – Q2H Position / Water bed

5.5. Protect Eyes by keeping closed / LubricantsProtect Eyes by keeping closed / Lubricants

6.6. Ranitin to prevent Stress ulcer / Stool softenerRanitin to prevent Stress ulcer / Stool softener

7.7. Aseptic Catherization / Intermittent catheteris’nAseptic Catherization / Intermittent catheteris’n

8.8. Passive Limb Exercises to prevent ContracturesPassive Limb Exercises to prevent Contractures

9.9. Calf exe / Stocking / Heparin to avoid DVTCalf exe / Stocking / Heparin to avoid DVT

BRAIN DEATHBRAIN DEATH

State of cessation of cerebral activity with State of cessation of cerebral activity with normal Heart function, Respiration being normal Heart function, Respiration being maintained by Ventilators.maintained by Ventilators.

Brain death is the Death of the IndividualBrain death is the Death of the Individual

Three Essential elements for DxThree Essential elements for Dx 1. Widespread Cortical Destruction (Unresponsive to all stimuli)1. Widespread Cortical Destruction (Unresponsive to all stimuli)

2.Global BS Damage (Loss of all BS reflexes)2.Global BS Damage (Loss of all BS reflexes)

3.Lower BS destruction – Complete Apnea3.Lower BS destruction – Complete Apnea

Exclude Drug induced / Hypothermic CNS Exclude Drug induced / Hypothermic CNS DepressionDepression

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