COMA

AND UNCONSCIOUSNESS

Abdul Gofir
Neurology 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

Reticular
Activating
Brain Stem System
 Cerebral Cortex
 Cognition
 Voluntary Movement
 Sensation
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 Neuronal Swelling

ICP>MAP is
incompatible
with life

Decreased Intracranial Increased Intracranial

Blood Flow Pressure
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 Syndrome
Ventral Pontine Infarct

 Complete Paralysis

 Preserved Consciousness

 Preserved Eye Movement

Minimally Responsive State
Static Encephalopathy

 Diffuse or Multi-Focal Brain Injury

 Preserved Brain Stem Function

 Variable Interaction with Environmental Stimuli

Clues from History
 Onset of symptoms
 sudden onset
 fluctuations
 Associated neurologic symptoms
 Medications
Neurologic Exam
 Assessment
 Descriptive, systematic
 Reference point for serial assessment
Exam goals
 Primary CNS event versus secondary
 Implications:
 short and long-term outcome
 investigations
Breathing
 Abnormalities of respiration can help localize but
almost always in the context of other signs
 Central-reflex Hyperpnea (midbrain-hypothalamus)
 Apneustic, cluster, Ataxic (Lower pons)
 Loss of automatic breathing (medulla)
Cranial Nerve Exam
 Systematic assessment of brainstem function via
reflexes
 Cranial 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 Responses
 Afferent Limb: Optic Nerve
 Efferent Limb: Parasympathetics via occulomotor
 Midbrain integrity/ tectum
 Uncal Herniation (3rd nerve dysfunction)
 Pupillary resistance to insult
Pupillary Light Responses
 Be aware of drug effects
 Systemic and Local
 State size, before and after light stimulation
 Specify right and left
Pupils: Localizing Value
 Pons-pinpoint pupils
 Symp. Dysfinction plus parasymp.irritation
 Midbrain-Large fixed pupils unresponsive to light,
hippus
 Horner’s- symp.dysfunction
 Unilateral dilation- parasymp. Dysfunction usually
due to 3rd nerve lesion
Ciliospinal Reflex
 1-2 mm pupillary dilatation evoked by noxious
cutaneous stimulation
 More prominent in sleep or coma than during
wakefulness
 Test integrity of symp.pathways in comatose patients
 Not particularly useful in evaluating brainstem
function
Corneal Reflex
 Afferent: Trigeminal Nerve
 Efferent: Third Nerve (Bell’s Phenomenon
and Facial Nerve (Eye closure)
 Tests dorsal midbrain (Bell’s) and pontine integrity
(Eye closure)
Eye Movements
 Before maneuvers attempted note resting position
 Midline
 Deviation suggests frontal/pontine damage
 Conjugate
 Dysconjugance suggests CN abn.
 Moving
 Roving, dipping, bobbing
Occulocephalic/ Calorics
 Same reflex elicited differently
 Afferent: Eighth nerve
 Efferent: 3,4,6 via MLF and PPRF
 Occulocephalics may also involve proprioceptive
afferents from the neck
Occulcephalic Reflex
 Brisk rotation of head with eyes held open
 Watch for contraversive movements
 Next:
 Flexion: eyes deviate up and eyelids open (doll’s head
phenomenon)
 Extension:eyes deviate downward
Caloric reflex
 Ensure TM integrity
 Elevation 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 away
 Comatose: deviation toward
 Wait 5 minutes, do other ear
Calorics
 Watch for conjugance of deviation
 To test vertical eye movements
 Both ears, cold water-downward gaze
 Both ears, warm water-upward gaze
Gag Reflex
 Afferent: Glossopharyngeal
 Efferent: Vagus
 Taken in context of other findings
Motor Exam
 Assess tone, presence of asterixis
 Response to painful stimuli
 none
 abnormal flexor
 abnormal extensor
 normal localization/withdrawal
 Avoid use of decerebrate/ decorticate
Reflexes
 Brainstem
 Deep tendon
 Biceps, brachioradialis, triceps
 Patellar, Achilles
 Plantar Responses
 Superficial skin
 Abdominal, cresmasteric
Uncal herniaiton
 Expanding lesions in lateral middle fossa
 Compression of hippocampal gyrus over free edge of
tentorium
 Three stages described
 Early third nerve
 Late third nerve
 Midbrain-Upper pons stage
Goals in Emergency
 Primary Neurological Process?
 evidence of raised ICP
 focal findings, especially that implicate brainstem
structures
 Secondary Processes
 signs of infection, toxic/metabolic processes
 relative lack of focality
Coma Mimics
 Akinetic mutism
 ‘Locked-in’ syndrome
 Catatonia
 Conversion reactions
Akinetic Mutism
 Silent, immobile but alert appearing
 Usually due to lesion in bilateral mesial frontal lobes,
bilateral thalamic lesions or lesions in peri-aqueductal
grey (brainstem)
“Locked-In’ Syndrome
 Infarction of basis pontis (all descending motor fibers
to body and face)
 May spare eye-movements
 Often spares eye-opening
 EEG is normal or shows alpha activity
Catatonia
 Symptom complex associated with severe psychiatric
disease with:
 stupor, excitement, mutism, posturing
 can also be seen in organic brain diease: encephalitis,
toxic and drug-induced psychosis
Conversion reactions
 Fairly rare
 Occulocephalics may or may not be present
 The 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 Opening
Never 1
To pain 2 Best Motor Response
To verbal 3 None 1
Spontaneous 4
Extensor 2
Best Verbal Response Flexor Posture 3
None 1 Withdrawal 4
Sounds 2 Localization 5
Inapp words 3 obeys 6
disoriented 4
oriented 5
Infectious Etiology

- History

- Fever

- Nuchal rigidity

- Kernigs, Brudzinski

- Rash
 Examination of the Comatose
Patient
History Neurologic Exam
Onset
Verbal responses
Recent complaints
oriented speech
Recent Injury
Prior Illness confused conversation
Medications inappropriate speech
incomprehensible speech
General Exam no speech
V.S. Eye opening
Trauma? spontaneous
Illness? verbal response
Dugs?
noxious response
Nuchal Rigidity
none
Pupillary reactions Corneal responses
present present
absent absent
Spont eye movts Repiratory pattern
orienting regular
roving periodic
misc ataxic
none
Motor responses
Oculocephalic responses obeys
normal localizes
full w/d
minimal abnormal flexion
none abnormal extension
Oculovestibular responses none
normal DTR’s
tonic conj Normal, incr, decr
dysconj Tone
none 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
Nutritional Therapy
 Asses nutritional status in coma patient
 to 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 supportif
 Jalan 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 nafas
 Alat yang dipakai
Perhatikan aliran darah
 Perfusi : perifer
 Ginjal : produksi urine
 Nadi : ritme, rate, pengisian
 Tekanan darah
 Diusahakan :
 Hemodinamik stabil
 Kondisi tensi normal
 Dihindari : Hipertensi/meninggi, shock
 Jenis Shock : hipovolemik, kardiogenik, sepsis, penimbunan
vena perifer (polling darah)
Cairan Tubuh
 Cegah hidrasi berlebihan
 Cairan hipotonik, hipoprotein & lama pakai ventilator
mudah terjadi hidrasi
 Tekanan osmotik dipertahankan dengan albumin
 Hindari Hiponatremia
Gas darah & Keseimbangan
Asam Basa
 Alat 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 Tube
 Pengeluaran isi lambung berguna :
 Mencegah aspirasi, intoksikasi
 Nutrisi parenteral
Posisi & Katheter Urine
 Hindari posisi Trendelenberg
 Posisi kepala 30 derajat lebih tinggi
 Pada Koma yang lama dihindari :
 Dekubitus
 Vena dalam trombosis (DVT) : pakai stocking

KATETER
 Kateterisasi untuk memudahkan penghitungan balans
cairan
Terapi Kausatif
 Infeksi?
 Perdarahan?
 Tumor?
 Metabolik?
 AVM?Aneurisma?
Anamnesis
 Apakah 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)