Coma PEMERIKSAAN KLINIK

DERAJAT KESADARAN (Alertness = Basic Arousal) Alert Letargic Stupr Coma OBSERVASI PERILAKU Riwayat perubahan perilaku (acute confusional states, agresif, dll) Perubahan mood dan emosi

F1 : PATOFISIOLOGI & PATOGENESIS F2 : Pemeriksaan Klinis (DD & DX) F3 : Managemen F4 : Brain Death

States of Altered Consciousness

State

Description of Patient

Lethargy
Obtunded

fatigued with minimal difficulty maintaining alertness

moderate reduction in alertness with decreased interest in environment, responsive to stimuli other than pain unresponsiveness with arousal only vigorous/painful stimulus, return to unresponsiveness with removal of stimulus

Stupor to

F1 : Pemeriksaan Klinis
DD dan DX

Glasgow Coma Scale 3-15

Eye Opening Never To pain To verbal Spontaneous

1 2 3 4

Best Verbal Response None 1 Sounds 2 Inapp words 3 disoriented 4 oriented 5

Best Motor Response None 1 Extensor 2 Flexor Posture 3 Withdrawal 4 Localization 5 obeys 6

Consciousness Is Dependent on:

1) An Intact Ascending Reticular Activating System (central tegmental fasiculus)
2) Direct Afferent Systems (raphe nucleus, locus ceruleus, parabrachialis)

The ARAS and Essential Neurotransmitters

Locus Coeruleus: Epinephrine Raphe Nucleus: Serotonin Basal Nucleus: Acetylcholine
MASUK f1

Common Etiologies of Coma

Approximate mortality Drug Overdose Metabolic Head Trauma Anoxia 5-10% 50% 50% 90%

Stroke
Status Epilepticus

80%
3-30%

Immediate assessment should focus on:

R/O Neurosurgical Etiology- neoplasm, bleed, impending herniation

R/O Infectious etiology

R/O Epileptic Etiology

R/O Metabolic Etiology

R/O Trauma Etiology

Etiologies-toxic metabolic
Drug overdose Narcotics, Tricyclics, Stimulants Metabolic Sepsis Hepatic encephalopathy Uremic encephalopathy Hypoglycemia Hypothyroidism ETOH withdrawal/intoxication

Typical Features of Metabolic Coma

- AMS usually precedes motor findings - Motor findings symmetric - Pupils small but reactive - Asterixis, myoclonus, tremor, and seizures common

Infectious Etiology
- History

- Fever
- Nuchal rigidity

- Kernigs, Brudzinski
- Rash

Signs of increased ICP/Herniation

Pupils
Unilateral dilated pupil Bilateral small poorly reactive pupils
Third nerve palsy Sixth nerve palsy Can be assessed by cold caloric Signs of papilledema?

Eye movements

Fundoscopy

Respiratory pattern?

Can be detected by a deterioration in mental status, pupils, or motor exam

-Withdrawal to pain transitioning to flexor withdrawal -Flexor withdrawal to extensor posturing
Decortication-Flexor withdrawal-lesion above red nucleus Decerebration-Extensor posturing-lesion below red nucleus

Suspected bacterial meningitis or SAH

For SAH, STAT CT of brain
If bacterial meningitis suspected, do not delay for CT- Start empiric therapy
Ceftriaxone 2 grams q12 hours IV Vancomycin 750-1000 mg q 12 hours IV Ampicillin 2 grams q 4 hours IV age > 65 or if immunocompromised 90% yield for SAH Notify neurosurgery stat if suspected

LP: L3-L4 interspace

Obtain opening pressure Cell count tubes 1 and 4 Tubes 2 and 3, Gram stain, Cocci, AFB, india ink, Protein and glucose

Increased ICP
-Hyperventilation: Reduces ICP immediately, peak effect 1-2 hours NO BENEFIT TO drop PCo2 < 25, Ideal = 30 - Mannitol: Onset in 30 minutes lasts 4-6 hours - Mannitol and lasix are synergistic. 1 - 2 grams/kg bolus 0.5 - 1 gram/kg q 6 hours Monitor sodium, osmolality, BUN - Hyperosmolality with 3% NaCl

Initial Management
Protect airwaySupport vitals If evidence of trauma, immobilize spine, get stat c-spine IV, Pulse ox, frequent vitals and neurochecks Intubate if GCS < 10 or if any question of ability to protect airway

MASUK f3

Stat fingerstick for dextrose CBC, electrolytes, BUN/Cr, Calcium, ABG, LFTs, ammonia, UA, serum and urine tox screen, blood cultures if febrile Dextrose (1 amp = 25 grams dextrose) Always follow with Thiamine 100 mg IM

Initial Management
If Narcotic OD suspected, give Naloxone 1 - 2 amps repeat in 15 minutes If benzodiazepine overdose suspected, Flumazenil .2 mg repeat q 1 minute up to 1.0 mg, may produce seizures.

MASUK F3

If ETOH withdrawal (72-96 hrs post ETOH) (confusion, hallucinations, tremor, tachycardia, HTN) Thiamine 100 mg/IM Librium 25-100 mg q6hrs For ETOH seizures (12-24 hours post withdrawal)

Give thiamine 100mg Stat fingerstick for dextrose Lorazepam 2 mg IV q 6-8 hours

Laboratory Work-up
Immediate Tests
Glucose Electrolytes CBC, BUN, Cr Osmolality ABG LP (if no mass lesion)
Deferred Tests
Tox Screen LFTs Ammonia Coags TSH, cortisol AED levels BCx/Ucx

EEG/SSEP

Evaluasi formasi edema serebri MRI

Edema otak komplikasi utama peny.otak Causa : cerebral ischemia; physical damage, CNS infections, brain tumors TIK meningkat KU memburuk

(Kimura et al., 2005)

Stroke, 2005;36:1259-1263

Examination of the Comatose Patient

History
Onset Recent complaints Recent Injury Prior Illness Medications

Neurologic Exam
Verbal responses
oriented speech confused conversation inappropriate speech incomprehensible speech no speech

General Exam
V.S. Trauma? Illness? Dugs? Nuchal Rigidity

Eye opening
spontaneous verbal response noxious response none

Pupillary reactions
present absent

Corneal responses
present absent

Spont eye movts

orienting roving misc none

Repiratory pattern
regular periodic ataxic

Oculocephalic responses
normal full minimal none

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

Oculovestibular responses normal tonic conj dysconj none

DTRs
Normal, incr, decr

Tone
Norm, 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