Coma Gawat Darurat 13-1-14
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UTHSCSA UTHSCSA Pediatric Resident Curriculum for the PICU Pediatric Resident Curriculum for the PIC MANAGEMENT AND EVALUATIO MANAGEMENT AND EVALUATIO OF THE COMATOSE PATIENT OF THE COMATOSE PATIENT
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Transcript of Coma Gawat Darurat 13-1-14
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MANAGEMENT AND MANAGEMENT AND EVALUATION OF THE EVALUATION OF THE COMATOSE PATIENTCOMATOSE PATIENT
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OBJECTIVESOBJECTIVES
• Primary Objective: The physician Primary Objective: The physician should be able to stabilize, evaluate, should be able to stabilize, evaluate, and treat the comatose patient in the and treat the comatose patient in the emergent setting. emergent setting.
• The physician should understand this The physician should understand this involves an organized, sequential, involves an organized, sequential, prioritized approach.prioritized approach.
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The Comatose PatientThe Comatose Patient
Primary ObjectivesPrimary Objectives• AAirwayirway
• BBreathingreathing
• CCirculationirculation• Treatment of rapidly progressive, dangerous Treatment of rapidly progressive, dangerous
metabolic causes of coma (hypoglycemia)metabolic causes of coma (hypoglycemia)• Evaluation as to whether there is significant Evaluation as to whether there is significant
increased ICP or mass lesions.increased ICP or mass lesions.• Treatment of ICP to temporize until surgical Treatment of ICP to temporize until surgical
intervention is possible.intervention is possible.
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The Comatose PatientThe Comatose Patient
Secondary ObjectivesSecondary Objectives
• The physician should understand and The physician should understand and recognize:recognize:
•ComaComa•Herniation syndromesHerniation syndromes•Signs of supratentorial mass lesionsSigns of supratentorial mass lesions•Signs of subtentorial mass lesionsSigns of subtentorial mass lesions
• The physician should be able to The physician should be able to develop the differential diagnosis of develop the differential diagnosis of metabolic coma.metabolic coma.
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The Comatose PatientThe Comatose Patient
NeurophysiologyNeurophysiology
• Consciousness requires:Consciousness requires:•An intact pontine reticular activating An intact pontine reticular activating systemsystem
•An intact cerebral hemisphere, or at An intact cerebral hemisphere, or at least part of a hemisphereleast part of a hemisphere
• Coma requires dysfunction of either the:Coma requires dysfunction of either the:•Pontine reticular activating system, Pontine reticular activating system, oror•Bihemispheric cerebral dysfunctionBihemispheric cerebral dysfunction
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The Comatose PatientThe Comatose Patient
ClassificationsClassifications
• SupratentorialSupratentorial lesions cause coma by either lesions cause coma by either widespread bilateral disease, increased widespread bilateral disease, increased intracranial pressure, or herniation.intracranial pressure, or herniation.
• InfratentorialInfratentorial lesions involve the RAS, lesions involve the RAS, usually with associated brainstem signsusually with associated brainstem signs
• MetabolicMetabolic coma causes diffuse hemispheric coma causes diffuse hemispheric involvement and depression of RAS, involvement and depression of RAS, usuallyusually without focal findingswithout focal findings
• PsychogenicPsychogenic
Plum and Posner, 1982
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Supratentorial Mass Supratentorial Mass LesionsLesions• HematomaHematoma• NeoplasmNeoplasm• AbscessAbscess• ContusionContusion• Vascular AccidentsVascular Accidents• Diffuse Axonal DamageDiffuse Axonal Damage
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Supratentorial Mass LesionsSupratentorial Mass Lesions
Subdural HematomaSubdural Hematoma
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Supratentorial Mass LesionsSupratentorial Mass LesionsAcute epidural hematoma and midline Acute epidural hematoma and midline shiftshift
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Severe head trauma with basilar skull Severe head trauma with basilar skull fracture, right temporal hematoma, cerebral fracture, right temporal hematoma, cerebral edema, hydrocephalus, and pneumocephalusedema, hydrocephalus, and pneumocephalus
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Supratentorial Mass LesionsSupratentorial Mass Lesions Cerebral AbscessCerebral Abscess
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Supratentorial Mass LesionsSupratentorial Mass Lesions
PathophysiologyPathophysiology
• Altered consciousness is based onAltered consciousness is based on•Increased intracranial pressureIncreased intracranial pressure•Herniation Herniation •Diffuse bilateral lesionsDiffuse bilateral lesions
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Herniation SyndromesHerniation Syndromes
Central herniation Central herniation Rostral caudal progression of Rostral caudal progression of respiratory, motor, and pupillary respiratory, motor, and pupillary findingsfindingsMay not have other focal findingsMay not have other focal findings
Uncal herniationUncal herniationRostral caudal progression Rostral caudal progression CN III dysfunction and contralateral CN III dysfunction and contralateral motor findingsmotor findings
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Herniation syndromesHerniation syndromes
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Normal AnatomyNormal Anatomy
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Transtentorial HerniationTranstentorial Herniation
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Normal BrainNormal Brain
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Transtentorial herniation and brainstem Transtentorial herniation and brainstem infarction in a patient with melanomainfarction in a patient with melanoma
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Supratentorial Mass LesionsSupratentorial Mass Lesions
Differential CharacteristicsDifferential Characteristics
Initiating signs usually of focal cerebral Initiating signs usually of focal cerebral dysfunctiondysfunctionSigns of dysfunction progress rostral to Signs of dysfunction progress rostral to caudalcaudalNeurologic signs at any given time Neurologic signs at any given time point to one anatomic area - point to one anatomic area - diencephalon, midbrain, brainstemdiencephalon, midbrain, brainstemMotor signs are often asymmetricalMotor signs are often asymmetrical
Plum and Posner, Plum and Posner, 19821982
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Rostral Caudal Rostral Caudal ProgressionProgression
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Rostral Caudal ProgressionRostral Caudal Progression
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Rostral Caudal ProgressionRostral Caudal Progression
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Infratentorial LesionsInfratentorial Lesions
• Cause coma by affecting reticular Cause coma by affecting reticular activating system in ponsactivating system in pons
• Brainstem nuclei and tracts usually Brainstem nuclei and tracts usually involved with resultant focal involved with resultant focal brainstem findingsbrainstem findings
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Infratentorial LesionsInfratentorial Lesions
Causes of ComaCauses of Coma
• NeoplasmNeoplasm• Vascular accidentsVascular accidents• TraumaTrauma• Cerebellar hemorrhageCerebellar hemorrhage• Demyelinating diseaseDemyelinating disease• Central pontine myelinolysis (rapid Central pontine myelinolysis (rapid
correction of hyponatremia)correction of hyponatremia)
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Infratentorial Mass LesionsInfratentorial Mass Lesions
Differential CharacteristicsDifferential Characteristics
• History of preceding brainstem History of preceding brainstem dysfunction or dysfunction or sudden onset sudden onset of comaof coma
• Localizing brainstem signs Localizing brainstem signs precede or precede or accompany onset of coma and always accompany onset of coma and always include oculovestibular abnormalityinclude oculovestibular abnormality
• Cranial nerve palsies Cranial nerve palsies usually presentusually present• ““Bizarre” respiratory patterns Bizarre” respiratory patterns common, common,
usually present at onset of comausually present at onset of coma
Plum and Posner, 1982Plum and Posner, 1982
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Metabolic ComaMetabolic Coma
EtiologiesEtiologies
• RespiratoryRespiratory– HypoxiaHypoxia– HypercarbiaHypercarbia
• ElectrolyteElectrolyte– HypoglycemiaHypoglycemia– HyponatremiaHyponatremia– HypercalcemiaHypercalcemia
•Hepatic Hepatic encephalopathyencephalopathy
•Severe renal Severe renal failurefailure
•InfectiousInfectious– MeningitisMeningitis– EncephalitisEncephalitis
•Toxins, drugsToxins, drugs
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Metabolic ComaMetabolic Coma
Differentiating FeaturesDifferentiating Features
• Confusion and stupor commonly precede Confusion and stupor commonly precede motor signsmotor signs
• Motor sings are usually symmetricalMotor sings are usually symmetrical• Pupillary reactions are usually Pupillary reactions are usually
preservedpreserved• Asterixis, myoclonus, tremor, and Asterixis, myoclonus, tremor, and
seizures are commonseizures are common• Acid-base imbalance with hyper- or Acid-base imbalance with hyper- or
hypoventilation is frequenthypoventilation is frequentPlum and Posner, 1982Plum and Posner, 1982
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Approach to the Comatose PatientApproach to the Comatose Patient
PrioritiesPriorities
• ABC’s are paramount!ABC’s are paramount!• Must prioritizeMust prioritize• Must ensure oxygen and substrate Must ensure oxygen and substrate
reach CNS and vital organs reach CNS and vital organs • Must address immediately life Must address immediately life
threatening conditions before threatening conditions before addressing CNS addressing CNS
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Approach to the Comatose PatientApproach to the Comatose Patient
Initial TreatmentInitial Treatment
• AirwayAirway• BreathingBreathing• CirculationCirculation• ABC - identify and address life ABC - identify and address life
threatening inadequaciesthreatening inadequacies• Treat rapidly progressive metabolic Treat rapidly progressive metabolic
disorders -- hypoglycemiadisorders -- hypoglycemia• Evaluate for intracranial hypertension Evaluate for intracranial hypertension
and imminent herniation and treatand imminent herniation and treat
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Management of the Comatose Patient Management of the Comatose Patient
AirwayAirway
• Evaluate -- is airway patent. Can patient Evaluate -- is airway patent. Can patient move air without obstruction. Is there move air without obstruction. Is there trauma or foreign body obstructing trauma or foreign body obstructing airwayairway
• Try chin lift to help open airway -- Try chin lift to help open airway -- protect cervical spineprotect cervical spine
• Place airway if indicated - nasal or oral Place airway if indicated - nasal or oral airway, intubation, or surgical airwayairway, intubation, or surgical airway
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Management of the Comatose PatientManagement of the Comatose Patient AirwayAirway
• Intubate (protecting neck) “Intubate (protecting neck) “anyone who anyone who will let you”will let you”– Any of the following are adequate criteriaAny of the following are adequate criteria
•GCS < 9GCS < 9•Airway not secure or openAirway not secure or open•Respiration not adequateRespiration not adequate•Any significant respiratory failureAny significant respiratory failure•Uncertainty regarding direction or rate of Uncertainty regarding direction or rate of
mental status changes, particularly if mental status changes, particularly if constant observation not available (during constant observation not available (during CT scans, etc..)CT scans, etc..)
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Management of the Comatose Patient Management of the Comatose Patient
BreathingBreathing
• Evaluate - is patient moving adequate Evaluate - is patient moving adequate air, is respiratory rate appropriate, is air, is respiratory rate appropriate, is gas exchange adequate, are breath gas exchange adequate, are breath sounds adequate and symmetricalsounds adequate and symmetrical
• Must assure oxygenation and ventilationMust assure oxygenation and ventilation• If intubated don’t forget to ventilateIf intubated don’t forget to ventilate• Identify and immediately treat problems Identify and immediately treat problems
- pneumothorax, airway obstruction, - pneumothorax, airway obstruction, etc..etc..
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Management of the Comatose PatientManagement of the Comatose Patient
CirculationCirculation
• Is patient in shock? Is patient in shock? •Check pulses, heart rate, blood pressure, Check pulses, heart rate, blood pressure,
perfusionperfusion•Remember hypotension is Remember hypotension is latelate sign of sign of
shockshock
• Start treatment for shockStart treatment for shock•Do not restrict fluids in comatose patient Do not restrict fluids in comatose patient
with inadequate intravascular volume. with inadequate intravascular volume. •Cardiac output and cerebral perfusion are Cardiac output and cerebral perfusion are
much more important than fluid restrictionmuch more important than fluid restriction
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Management of the Comatose PatientManagement of the Comatose Patient
CirculationCirculation
• Use isotonic solutions and blood, as Use isotonic solutions and blood, as indicated.indicated.
• Do not use hypotonic solutions to treat Do not use hypotonic solutions to treat shock, particularly patients with coma shock, particularly patients with coma or possible cerebral edemaor possible cerebral edema
• Identify life threatening hemorrhage Identify life threatening hemorrhage and control it.and control it.
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Management of the Comatose PatientManagement of the Comatose Patient
Disability - NeurologicDisability - Neurologic
• Glasgow coma scaleGlasgow coma scale– Provides easily reproducible and somewhat Provides easily reproducible and somewhat
predictive basic neurologic exampredictive basic neurologic exam– This allows rapid assessment and record of This allows rapid assessment and record of
baseline neurologic statusbaseline neurologic status– Allows physician to track neurologic changes Allows physician to track neurologic changes
over time and multiple examinersover time and multiple examiners
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Glasgow Coma ScaleGlasgow Coma Scale
• Three components. Score derived by Three components. Score derived by adding the score for each component.adding the score for each component.
•Eye opening (4 points)Eye opening (4 points)•Verbal response (5points)Verbal response (5points)•Best motor response (6 points)Best motor response (6 points)
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Glasgow Coma ScaleGlasgow Coma Scale
• Eye openingEye opening• 4 - spontaneous4 - spontaneous• 3 - to speech3 - to speech• 2 - to pain2 - to pain• 1 - none1 - none
• Verbal ResponseVerbal Response• 5 - oriented5 - oriented• 4 - confused conversation4 - confused conversation• 3 - inappropriate words3 - inappropriate words• 2 - incomprehensible sounds2 - incomprehensible sounds• 1 - none1 - none
• Best Motor ResponseBest Motor Response• 6 - obeys6 - obeys• 5 - localizes5 - localizes• 4 - withdraws4 - withdraws• 3 - abnormal 3 - abnormal
flexionflexion• 2 - abnormal 2 - abnormal
extensionextension• 1 - none1 - none
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Management and Evaluation of the Comatose Management and Evaluation of the Comatose PatientPatient
PracticalitiesPracticalities
• During ABC’s and secondary survey:During ABC’s and secondary survey:– Have someone start IV and obtain labsHave someone start IV and obtain labs
•ABG’sABG’s•Chem 7, LFT’s, ammonia, coagulation Chem 7, LFT’s, ammonia, coagulation
studiesstudies• Toxin screensToxin screens•DextrostickDextrostick
– As soon as IV in and labs drawn, giveAs soon as IV in and labs drawn, give•Glucose (D25, 2 - 4 cc per kilogram)Glucose (D25, 2 - 4 cc per kilogram)•Consider thiaminConsider thiamin
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Management of the Comatose PatientManagement of the Comatose Patient
Secondary SurveySecondary Survey
• Do a quick general exam of the entire Do a quick general exam of the entire body to identify acute life threatening body to identify acute life threatening conditionsconditions
• In general, major thoracic or abdominal In general, major thoracic or abdominal trauma takes precedence after ABC’strauma takes precedence after ABC’s
• Only very rarely is acute neurosurgical Only very rarely is acute neurosurgical intervention appropriate before other intervention appropriate before other acute life threatening injuries are acute life threatening injuries are stabilized (except protection of c spine by stabilized (except protection of c spine by immobilization)immobilization)
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Neurologic ExaminationNeurologic Examination
Secondary SurveySecondary Survey
• General motor examGeneral motor exam– look for focal deficits, posturing (decerebrate or look for focal deficits, posturing (decerebrate or
decorticate)decorticate)
• Reflexes, toneReflexes, tone• Cranial nerve and brainstem functionCranial nerve and brainstem function
– Pupillary response - diencephalon, midbrain, Pupillary response - diencephalon, midbrain, brainstem, CN’s II and IIIbrainstem, CN’s II and III
– Corneal Reflex - CN’s V, VII, brainstemCorneal Reflex - CN’s V, VII, brainstem– Oculocephalic Reflex - not if neck injury possible. Oculocephalic Reflex - not if neck injury possible.
Tests CN’s III, IV, VI, VIII, and brainstem.Tests CN’s III, IV, VI, VIII, and brainstem.– Oculovestibular (calorics) can be done if neck Oculovestibular (calorics) can be done if neck
questionable.questionable.
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Neurologic ExamNeurologic Exam
Oculovestibular TestingOculovestibular Testing
• Check for tympanic perforationCheck for tympanic perforation• Instill 120 cc cold water over 2 minutesInstill 120 cc cold water over 2 minutes• Conscious patient - COWSConscious patient - COWS• Coma with intact pathways - tonic eye Coma with intact pathways - tonic eye
deviation to side of colddeviation to side of cold
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Management and Evaluation Management and Evaluation of the Comatose Patientof the Comatose Patient
• Does the patient have a rapidly Does the patient have a rapidly progressive intracranial lesion?progressive intracranial lesion?
• Assume yes, if:Assume yes, if:– 1. Any evidence of brainstem abnormality1. Any evidence of brainstem abnormality– 2. Any evidence of rostral caudal 2. Any evidence of rostral caudal
progressionprogression– 3. Any focal deficits3. Any focal deficits– 4. Progression of motor exam from 4. Progression of motor exam from
withdrawal to posturingwithdrawal to posturing
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Does the patient have a rapidly Does the patient have a rapidly progressive intracranial lesion?progressive intracranial lesion?
• If any factor is present, assume If any factor is present, assume increased intracranial pressure is increased intracranial pressure is present and herniation and irreversible present and herniation and irreversible damage imminentdamage imminent– IntubateIntubate– HyperventilateHyperventilate– MannitolMannitol– CT scan, neurosurgical consultationCT scan, neurosurgical consultation
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Does the patient have a rapidly Does the patient have a rapidly progressive intracranial lesion?progressive intracranial lesion?
• If none of the findings are present, surgical If none of the findings are present, surgical lesion less likely than metabolic causelesion less likely than metabolic cause
• Mass lesion still possible, though - CT scanMass lesion still possible, though - CT scan• Urgency of intubation less but should Urgency of intubation less but should
considerconsider– Will patient deteriorate, particularly while out of Will patient deteriorate, particularly while out of
constant observation (CT scanner)?constant observation (CT scanner)?– Can patient protect airway?Can patient protect airway?
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Management and Evaluation of the Comatose Management and Evaluation of the Comatose PatientPatient
Additional PointsAdditional Points
• If scans normal, probably metabolicIf scans normal, probably metabolic• Emergent causes of metabolic coma Emergent causes of metabolic coma
(even after ABC’s)(even after ABC’s)– Hypoglycemia - give glucoseHypoglycemia - give glucose– Infection - LP, consider antibiotics, acyclovir. Infection - LP, consider antibiotics, acyclovir.
If diagnostic studies delayed, treat firstIf diagnostic studies delayed, treat first– Certain toxins - antidepressants, salicylates, Certain toxins - antidepressants, salicylates,
theophylline, alcohol (methanol and theophylline, alcohol (methanol and ethylene glycol)ethylene glycol)
– Subclinical status epilepticusSubclinical status epilepticus
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Criteria for CNS Criteria for CNS Determination of Death Determination of Death
(Brain Death)(Brain Death)• Irreversible comaIrreversible coma• Absence of cortical functionAbsence of cortical function• Absence of brainstem functionAbsence of brainstem function• ApneaApnea• 2 examinations with interval according to 2 examinations with interval according to
patient’s agepatient’s age• Ancillary testsAncillary tests
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Irreversible ComaIrreversible Coma
• Known etiology and or reversible causes Known etiology and or reversible causes ruled outruled out
• Must have an absence ofMust have an absence of– Hypothermia (>32.5Hypothermia (>32.500C)C)– Neuromuscular blockadeNeuromuscular blockade– Shock or significant hemodynamic instabilityShock or significant hemodynamic instability– Significant levels of sedativesSignificant levels of sedatives– Severe metabolic distrubanceSevere metabolic distrubance
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Basic exam 1 - PainBasic exam 1 - Pain
• Cerebral motor response to painCerebral motor response to pain– Supraorbital ridge, the nail beds, trapeziusSupraorbital ridge, the nail beds, trapezius– Motor responses may occur spontaneously Motor responses may occur spontaneously
during apnea testing (spinal reflexes)during apnea testing (spinal reflexes)– Spinal reflex responses occur more often in Spinal reflex responses occur more often in
youngyoung– If pt had NMB, then test w/ train-of-fourIf pt had NMB, then test w/ train-of-four
• Spinal arcs are intact!Spinal arcs are intact!
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Basic exam 2 - PupilsBasic exam 2 - Pupils• Round, oval, or irregularly shaped Round, oval, or irregularly shaped • Midsize (4-6 mm), but may be totally dilatedMidsize (4-6 mm), but may be totally dilated• Absent pupillary light reflexAbsent pupillary light reflex
– Although drugs can influence pupillary size, the Although drugs can influence pupillary size, the light reflex remains intact light reflex remains intact onlyonly in the absence of in the absence of brain deathbrain death
– IV atropine does not markedly affect responseIV atropine does not markedly affect response– Paralytics do not affect pupillary sizeParalytics do not affect pupillary size– Topical administration of drugs and eye trauma Topical administration of drugs and eye trauma
maymay influence pupillary size and reactivity influence pupillary size and reactivity– Pre-existing ocular anatomic abnormalities may Pre-existing ocular anatomic abnormalities may
also confound pupillary assessment in brain deathalso confound pupillary assessment in brain death
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Basic exam 3Basic exam 3Eye movementEye movement
• Oculocephalic reflex = doll’s eyesOculocephalic reflex = doll’s eyes
• Oculovestibular reflex = cold caloric test Oculovestibular reflex = cold caloric test
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Confirmatory testingConfirmatory testing
• 4 vessel angiography4 vessel angiography
• EEGEEG
– 30 minutes30 minutes
• Cerebral blood flow = perfusion scanCerebral blood flow = perfusion scan
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Possible CausesPossible Causes
• AAlcohollcohol• EEpilepsypilepsy• IInsulinnsulin• OOverdoseverdose• UUremia (and remia (and
other metabolic other metabolic causes)causes)
• TTraumarauma• IInfectionnfection• PPsychiatricsychiatric• SStroke, syncopetroke, syncope
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SeizuresSeizures
Anything that injures brain can cause Anything that injures brain can cause seizures (AEIOU/TIPS) seizures (AEIOU/TIPS)
Do Do notnot assume seizures are due to assume seizures are due to idiopathic epilepsy until proven idiopathic epilepsy until proven otherwiseotherwise
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Status EpilepticusStatus Epilepticus
>> 2 seizures without intervening 2 seizures without intervening conscious periodconscious period
Immediate Life ThreatImmediate Life ThreatManagementManagement
Secure airwaySecure airwayAssist breathing with OAssist breathing with O22
TransportTransportRequest ALS interceptRequest ALS intercept
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SyncopeSyncope
• FaintingFainting• Sudden, temporary loss of Sudden, temporary loss of
consciousnessconsciousness• Caused by lack of blood flow to Caused by lack of blood flow to
brainbrain
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CausesCauses
• Stress, fright, pain (vasovagal syncope)Stress, fright, pain (vasovagal syncope)• Orthostatic hypotension (BP fall on Orthostatic hypotension (BP fall on
standing)standing)– Decreased blood volumeDecreased blood volume– Increased size of vascular spaceIncreased size of vascular space
• Decreased cardiac outputDecreased cardiac output• Prolonged forceful coughingProlonged forceful coughing
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ManagementManagement
• ABCsABCs• Keep patient supine, elevate lower Keep patient supine, elevate lower
extremitiesextremities• OxygenOxygen• Assess underlying causeAssess underlying cause
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