Monday, February 04, 2013

Dr. Raj Gopal. V

Definition of COMA
Coma is defined as a sleeplike state with total absence of awareness of self and the environment, even after vigorous external stimulation. Coma is the most severe form of unresponsiveness, and by definition, comatose patients lie with their eyes closed. In general a comatose person is: Apparently asleep. Closing the eyes. Not talking. Unresponsive to instructions. Without any voluntary movements.
Monday, February 04, 2013

Dr. Raj Gopal. V

The various states of consciousness

For consciousness to be intact the cerebral hemispheres must be activated by the Reticular Activating System in the brainstem.

Conscious state

Alert and oriented

Drowsy

Sleepy but can be woken up Unconscious but responds to vigorous stimulation

Stupor

Coma

Unconscious and unresponsive

(Never lasts more than 2-4 weeks)

PVS
(Persistent Vegetative State)

All cognitive functions lost. Maybe awake but totally unresponsive. Breathing, circulation and internal organ functions intact. May last for years.

Monday, February 04, 2013

Dr. Raj Gopal. V

Pathophysiology of coma
Primarily 2 mechanisms: A diffuse insult to both cerebral hemispheres. A focal lesion in the Reticular Activating System (RAS) in the upper Pons, midbrain or the Diencephalon. The Big-3 causes: Stroke, Trauma, Drug overdose (STD!).
Monday, February 04, 2013

Dr. Raj Gopal. V

COMA

RAS

(Diencephalon)

COMA

Monday, February 04, 2013

Dr.(Pons, Medulla) Raj Gopal. V

Causes of COMA
Two broad categories: Structural or surgical and Metabolic or Medical.
Structural/Surgical: Diffuse damage to both cerebral hemispheres due to vascular damage or raised intracranial pressure. Medical/Metabolic: Diffuse insult to both cerebral hemispheres by toxins, either from within or from outside.

Monday, February 04, 2013

Dr. Raj Gopal. V

Causes of COMA Remember AEIOU-TIPS

A: Alcohol. E: Epilepsy or Exposure to heat and cold I: Insulin (Diabetic emergencies) O: Overdose or Oxygen deficiency U: Uremia (kidney failure) T: Trauma (Shock or head injury) I: Infection or Iatrogenic. P: Psychosis or poisoning. S: Strokes. There are 424 causes of COMA!
Monday, February 04, 2013

Dr. Raj Gopal. V

Causes of Surgical or Structural COMA

Trauma: Subdural/Epidural/Penetrating head injuries, brain contusions. Intracranial Hemorrhage: Subarachnoid or intracerebral. Ischemic Stroke. Diffuse microvascular abnormalities like purpura, Cerebral Malaria, Rocky Mountain Spotted Fever. Tumors, either primary brain tumors or metastasis.

Monday, February 04, 2013

Dr. Raj Gopal. V

Causes of Metabolic or Medical COMA

Drug overdose: Benzodiazepines, Barbiturates, Opioids, Anti-depressants. Infections: Bacterial meningitis, Encephalitis, Sepsis. Endocrine disorders: Diabetic emergencies, Myxedema, hyperthyroidism. Metabolic causes: Hyponatremia, Hypernatremia, Uraemia, Hypoxia, hepatic coma, Hypertensive encephalopathy. Toxic: Carbon Monoxide poisoning, Alcohol, Acetaminophen Overdose. Medication side effects. Hypothermia or hyperthermia. Deficiency states: Thiamine (In alcoholics) and Niacin.
Monday, February 04, 2013

Dr. Raj Gopal. V

Differences
Differences between Structural or surgical and Metabolic or Medical.
Structural/Surgical: Focal neurological signs, dilated and unreactive pupils and increased intracranial pressure. Medical/Metabolic: Reactive pupils, no focal neurological signs and normal intracranial pressures.

Monday, February 04, 2013

Dr. Raj Gopal. V

Diagnosis of COMA
History from third parties like family, friends and emergency medical personnel. Ask relevant questions. Clinical Examination: Quick and precise. Rapid and appropriate investigations: To find cause and institute appropriate treatment.

Monday, February 04, 2013

Dr. Raj Gopal. V

Assessment of COMA
The level of coma is assessed by the Glasgow Coma Scale. A quick assessment is the AVPU scale, used by emergency medical personnel: A: V: P: U: Alert. Responds to verbal commands. Responds to pain. Unresponsive - - - - - Proceed to GCS.

Monday, February 04, 2013

Dr. Raj Gopal. V

Assessment of COMA
The level of coma is assessed by the Glasgow Coma Scale. GCS assesses: Best verbal response. Best motor response. Level of stimulus needed to make the patient open the eyes.

Monday, February 04, 2013

Dr. Raj Gopal. V

The Glasgow Coma Scale

EYE OPENING
Spontaneous To speech To pain No response 4 3 2 1

MOTOR RESPONSE
Obeys Localizes Withdraws Abnormal flexion Extension Posturing No response 6 5 4 3 2 1

VERBAL RESPONSE
Oriented Confused conversation Inappropriate words Incomprehensible sounds No response
Monday, February 04, 2013

5 4 3 2 1
Dr. Raj Gopal. V

Total score: E + M + V Range: 3 15. Mild coma: 13 15 Moderate coma: 9 12 Severe coma: < 8

Examination of a Comatose patient

Baseline: HR, BP, Rectal temperature, Oxygen saturation and capillary Glucose. Response to external stimuli: None. Signs of trauma. Skin and mucus membranes survey: hyperpigmentation, cherry red color, anaemia, jaundice, rashes, IV drug abuse sites, myxoedema. Any MedicAlert bracelets or cards? Breath smell: Ketones, alcohol, Solvents. Examine RS, CVS, PA. Neurological examination including meningeal signs.

Monday, February 04, 2013

Dr. Raj Gopal. V

Neurological examination
The neurological examination focuses on 4 components. Respiratory patterns. Pupillary responses. Eye movements. Motor responses.
The most important examination in coma (to identify the cause) is the examination of the pupillary response and eye movements.
Monday, February 04, 2013

Dr. Raj Gopal. V

Respiratory patterns
Pattern Cheyne-Stokes Lesion Forebrain to pons Description Hyperventilation and hypoventilation with pauses. Rapid, deep breathing Prolonged inspiratory gasp followed by a pause and then expiration Periodic breathing with irregular frequency and amplitude, along with variable pauses Irregular in rate and rhythm

Central Neurogenic Midbrain to pons Hyperventilation Apneustic breathing Cluster breathing Pons High medullary lesions Medulla

Ataxic breathing

Monday, February 04, 2013

Dr. Raj Gopal. V

Pupillary responses
Most important part of examination. Pupils that react to light and are equal in size: Metabolic or medical coma. Unreactive, unequal and dilated pupil: Neurosurgical emergency. Pinpoint pupils: Pontine lesions or opiate toxicity. Bilateral dilated, unresponsive pupils: Anoxia, severe midbrain damage or anticholinergic drugs. No pupillary abnormality: Excludes lesions below pons and above thalamus.

Monday, February 04, 2013

Dr. Raj Gopal. V

Eye movements
Roving, slow, conjugate, lateral to and fro movements: Metabolic encephalopathies or bilateral lesions above brainstem. Ocular bobbing: Rapid downward jerk and slow return to midposition of both eyes: Bilateral pontine lesions. Ocular dipping: Slow downward dipping followed by brisk return: Diffuse cerebral damage. Skew deviation in horizontal plane; Cerebellar or pontine lesion. Dolls eye reflex: Normally when the head is turned in a lateral plane the eyes move in the opposite direction. Absence of this response indicates brainstem lesion. Caloric testing: 40-60 mL of ice cold water in the ears will cause the eyes to move towards the irrigated ear. Absence indicates brainstem damage.
Monday, February 04, 2013

Dr. Raj Gopal. V

Motor responses
Spontaneous movements always good sign. One side paralyzed: Suspect lesion in brain on the side not moving. Decorticate posturing: Arms flexed and legs extended indicates lesions above brainstem or a metabolic cause. Decerebrate posturing; Arms extended and legs extended indicates bilateral midbrain or pontine lesion. Worse prognosis. Also seen in metabolic conditions sometimes. Myoclonus: Non-rhythmic jerking in single or multiple muscle groups suggests metabolic encephalopathies (hepatic chiefly).

Monday, February 04, 2013

Dr. Raj Gopal. V

Investigations
Full blood counts: Infections. Biochemistry: Electrolytes, sugar, LFTs, KFTs. Arterial blood gases: Oxygen, CO2, pH, HCO3. Blood cultures. Alcohol levels. Drug screen (urine and blood) Lumbar puncture: Infections. CT Scans in case of trauma, bleeds, hemorrhage. MRIs where possible. Thyroid function tests (rarely) Electroencephalogram (EEG) & ECG. CXR. Blood slides for Malaria!!
Monday, February 04, 2013

Dr. Raj Gopal. V

Management
Immediate management in hospital: Never forget ABC: Airway, Breathing, Circulation. COMA COCKTAIL: 50 mL of 50% Dextrose + Thiamine 100 mg + Naloxone 0.4 mg (adults). Stop seizures with anti-epileptics. Treat metabolic disturbances. Lower intracranial pressure. Treat infections. Mechanical ventilation, IV lines and Ryles tubes.

Monday, February 04, 2013

Dr. Raj Gopal. V

Specific Management
Further management depends on the cause always. Diabetes, hepatic coma, electrolyte imbalances, endocrine causes etc: Correction of metabolic derangements. Trauma: Neurosurgery. Strokes, heart attacks, respiratory failure, hypoxia, hypothermia: Correct underlying causes. Medication/drug overdose: Specific antidotes. Meningitis and infections: Antibiotics. Raised ICP: Mannitol and Dexamethasone.

Monday, February 04, 2013

Dr. Raj Gopal. V

Long-term Management
Intensive nursing care. Recovery position. Mechanical ventilation. Pressure sores prevention. Care of the eyes. Airway clearance by bronchial toilet. Fluid and nutrition. Catheterization of bladder. Bowel care Disposable diapers. Physio to protect muscles and joints. DVT prophylaxis? Vital signs monitoring. Neurological monitoring.
Monday, February 04, 2013

Dr. Raj Gopal. V

WORST PROGNOSIS: Structural damage Subarachnoid Hemorrhage Cerebrovascular causes

GOOD PROGNOSIS: Metabolic causes. If no recovery in 4 weeks progresses to PVS. INDICATORS OF PROGNOSIS: Depth of coma as by GCS Pupillary reflexes. Eye movements. Motor responses. Age.

On Day I: No corneal reflex No pupillary reflex Decerebrate posture

Monday, February 04, 2013

Dr. Raj Gopal. V

Complications

Pressure sores. Bladder infections. Pneumonia: Hospital acquired or ventilator associated. Persistent Vegetative State.

Monday, February 04, 2013

Dr. Raj Gopal. V

Persistent Vegetative State

A note on PVS Permanent condition that emerges after severe brain injury. Normal sleep-wake cycles and eyes that open to verbal stimuli. No cognitive function. Cannot localize pain, or follow verbal commands. Blood pressure and respiration maintained. Synonyms: Coma vigil, Cerebral death, Total dementia. Very slim chances that the individual might recover.

Monday, February 04, 2013

Dr. Raj Gopal. V

Brain death
Brain death is different from coma and PVS Complete lack of activity anywhere in the brain. Kept alive through artificial means. Clinically and legally dead. Confirmatory EEG for legal purposes: Isoelectric flat line. Tests: Shine a light into eyes, corneal reflex, pain sensation, caloric tests, gag or cough reflex tested and removal from ventilator for short period to see if it stimulates respiration. Organs for transplantation if there is consent.

Monday, February 04, 2013

Dr. Raj Gopal. V

SUMMARY
Quick history from relatives and friends. Quick medical examination. Immediate transfer to specialized centers. Assessment of Coma depth. Detailed neurological evaluation. Basic Laboratory investigations. Specialized investigations. Correct underlying cause where possible. Refer for specialist care if required. Ongoing care of the patient. Recovery --------- Congratulations! Progression to PVS or brain death.
Monday, February 04, 2013

Dr. Raj Gopal. V

Monday, February 04, 2013