COMA

APPROACH , CAUSES AND EXAMINATION (INTRODUCTION)

APPROACH TO THE CASE

• FIRST ABCTHEN O2, IV ACCESS (DRAW BLOOD SAMPLE)

• IF HYPOGLYCEMIA 50% DEXTROSE

• ALWAYS EXCLUSE CERVICAL SPINE INJURY

• THEN FURTHER HISTORY AND ASSESSMENT

GLASGOW COMA SCALE

• COMPONENTS– EYE RESPONSE– VERBAL RESPONSE– MOTOR RESPONSE

GCS – EYE RESPONSE

• EYE RESPONSE4- spontaneous opening3- opening to speech2- opening to pain1- NONE

GCS – VERBAL SCORE• 5- ORIENTED• 4- CONFUSED• 3 – INAPPROPRIATE• 2- INCOMPREHENSIBLE WORDS• 1 – NONE

• VT – USED IN INTUBATED PATIENTS, MAKES THE ASSESSMENT BY GCS SCORE LESS EFFICIENT ( SO, IT RISES THE “”FOUR”” SCORE- FULL OUTLINE OF UNRESPONSIVENESS)

GCS – MOTOR SCORE

• 6- OBEYING COMMANDS• 5 – LOCALISING PAIN• 4 – WITHDRAWL TO PAIN• 3 – DECORTICATE• 2 – DECEREBRATE• 1 - NONE

FOUR SCORE

• FULL OUTLINE OF UNRESPONSIVENESS

• COMPONENTS• EYE RESPONSE• MOTOR RESPONSE• BRAIN STEM REFLEXES• BREATHING PATTERN

FOUR SCORE - BREATHINGPATTERN

• 4 – NOT INTUBATED , REGULAR BREATHING • 3 – NOT INTUBATED, CHEYNES STOKES

BREATHING• 2 – NOT INTUBATED, IRREGULAR BREATHING• 1 - INTUBATED, BREATHES ABOVE

VENTILATOR RATE• 0 – INTUBATED, BREATH BY VENTILATOR OR

APNEA

FOUR SCORE – BRAIN STEM REFLEXES

• 4 – PUPIL AND CORNEAL REFLEXES +• 3 – ONE PUPIL WIDE AND FIXED• 2 – PUPIL OR CORNEAL REFLEXES ABSENT• 1 – PUPIL AND CORNEAL REFLEX ABSENT• 0 – PUPIL, CORNEAL AND COUGH REFLEX

ABSENT

FOUR SCORE – EYE COMPONENTS

• EYE COMPONENTS• 4 – OPENING OR OPENED TRACKING TO

COMMENTS• 3 – OPENED NOT TRACKING• 2 – OPENS TO LOUD VOICE• 1 – OPENS TO PAIN• 0 – EYES CLOSED EVEN AFTER PAIN

FOUR SCORE – MOTOR COMPONENTS

• 4 – THUMBS UP, FIST SIGN• 3 – LOCALISING TO PAIN• 2 – FLEXION RESPONSE TO PAIN• 1 – EXTENSION RESPONSE TO PAIN• 0 – NO RESPONSE TO PAIN

FOUR SCORE

• WAS DEVELOPED IN MAYO CLINIC

• IT HAS GOOD SENSITIVITY , SPECIFITY SCORES

• SINCE IN INTUBATED PATIENTS, CLINICAL JUDGEMENT BY GCS SCORE IS DIFFICULT.. ON THESE SITUATIONS IT CAN BE USED

causes

• Metabolic– DM– HEPATIC FAILURE– RENAL FAILURE– HYPOTHERMIA– HYPOTHYROIDISM– RESPIRATORY FAILURE– HYPOXIC ENCEPHALOPATHY– HYPOGLYCEMIA

• DRUGS

– LOOK FOR PUPIL• MOSTLY ARE SYMPATHETIC DRUGS, SO THERE WILL BE

DILATED PUPILS ON ITS USAGE

STRUCTURAL CAUSES OF COMA

• MENINGITIS• ENCEPHALITIS• SAH• EPILEPSY• HEAD INJURY• HYPERTENSIVE ENCEPHALITIS

LOCALISED LESION

• IT CAN BE• SUPRATENTORIAL LESION– CAUSES DAMAGE TO DEEP DIENCEPHALIC STRUCTURE

• SUBTENTORIAL LESION

– CAUSE DAMAGE TO BRAINSTEM

SUPRATENTORIAL LESION

• CEREBRAL HEMORRHAGE• CEREBRAL INFARCTION WITH EDEMA• SUBDURAL HEMATOMA– Can be acute/subacute/chronic• Gradual decline in consciousness

SUPRATENTORIAL LESION

• TUMOUR• CEREBRAL ABSCESS• PITUITARY APOPLEXY

SUBTENTORIAL LESION

• CEREBELLAR HEMORRHAGE• PONTINE HEMORRHAGE• BRAIN STEM INFARCTION• TUMOUR• CEREBELLAR ABSCESS• SECONDARY EFFECTS OF TRANSTENTORIAL

HERNIATION OF BRAIN DUE TO CEREBRAL MASS LESION

HISTORY ALWAYS IMPORTANT

• IT CAN BE• ACUTE• SUBACUTE• CHRONIC

ACUTE ONSET

• TRAUMA

• If there is lucid interval – highly suggestive of EDH

• TRAUMA WITH CONCUSSION FOLLOWED BY FEW DAYS LATER BY FLUCTUATING DROWSINESS AND STUPOR

• HISTORY OF HEADACHE BEFORE COMA- MAY SIGNIFIES THERE MAY BE TUMOUR

HISTORY OF SEIZURES

• IT MAY INDICATE EITHER– Encephalitis– Meningitis– Abscess– Tumours

History of drug abuse

• There will be a traces in the surrounding

PSYCHOLOGICAL COMA

• RARE

EXAMINATION OF COMA PATIENT

• PATIENT APPEARANCE BUILT, CLEANLINESS, ALCOHOL SMELL+/-

ANY SIGN OF EXTERNAL INJURY

INJURIES IN HEAD?????

BASIC NEUROLOGICAL EXAMINATION

• ASSESS LEVEL OF CONSCIOUSNESS BY GCS SCOE

• LOOK FOR SIGNS OF HEAD INJURY

• SPLINT THE NECK, UNTIL CERVICAL SPINE INJURY EXCLUDED

• IF THERE IS NO NECK INJURY (( BY CLINICAL AND RADIOLOGICAL ) CHECK FOR NECK STIFFNESS

• CHECK PUPIL SIZES

• NORMAL PUPIL SIZE – 2 – 6 MM

• PIN POINT PUPIL - <1 MM– PONTINE HEMORRHAGE– MORPHINE/HEROIN

• SMALL PUPIL (1-2.5MM)

– METABOLIC ENCEPHALOPATHY– DAMAGE TO SYMPATHETIC PATHWAY IN

HYPOTHALAMUS

• ONE SIDE PUPIL DILATED AND FIXED AND OTHER SIDE PUPIL NORMAL– WARNING :: TEMPORAL LOBE HERNIATION AND

PRESSING ON THE OCULOMOTOR NERVE

• LARGER PUPILS– MAY DUE TO ATROPINE LIKKE DRUGS

– LSD– AMPHETAMINE– COCAINE• As these are sympathomimetics

If there is head injury• If there is head injury

• Follow the nice guidelines for CT HEAD– GCS <13/15– GCS <15 AFTER 2 HOURS OF INJURY– PERSISTENT VOMITTING– OLD AGE– ON ANTICOAGULANTS– FND– POST –TRAUMATIC SEIZURE– SUSPECTED OPEN OR DEPRESSED FRACTURE

• SKULL XRAYS THOUGH IT SERVES NO DIAGNOSTIC USE IN ADULTS, IT IS COMMONLY USED IN CHILDREN

IF THERE IS A BLEED ON CT SCAN

• MANAGEMENT BASED ON VOLUME OF THE BLEED AND MIDLINE SHIFT IN MM ONLY, IRRESPECTIVE OF GCS

• SDH >10MM3 AND MIDLINE SHIFT >5 MM – SURGERY

• EDH >30CM3 – SURGERY• ICH, CONTUSION ->50CM3 - SURGERY

• MAINTAINING THE CEREBRAL PERFUSION PRESSURE IS IMPORTANT..

• AS FALL IN PRESSURE BELOW THIS WORSEN THE NEUROLOGICAL STATUS.

• ALSO REMEMBER, THE AMOUNT OF BLOOD NEEDED BY GREY AND WHITE MATTER IS DIFFERENT

• GREY MATTER – 100ML/G/MIN• WHITE MATTER – 20 ML /G/MIN

• COMA WITHOUT FOCAL NEUROLOGICAL SIGN AND NECK STIFFNESS AND NORMAL DOLL EYE RESPONSE – MOSTLY METABOLIC

• COMA WITH NECKSTIFFNESS – CAUSES

• SAH• ENCEPHALITIS• ICH• CEREBRAL MALARIA

DOLL EYE RESPONSE(VESTIBULO – OCULAR REFLEX)

• REFLEX CAN BE TESTED BY RAPID HEAD IMPULSE TEST OR HALMAGYI-CURTHOYS TEST

VOR

• IF U MOVE THE HEAD IN ANY DIRECTION, IF THE VESTIBULO OCULO SYSTEM IS INTACT, IT HELP TO KEEP THE EYE IN NEUTRAL POSITION

VESTIBULO OCULAR REFLEX AND DRUG INDUCED COMA

• IN MOST CASES OF DRUG INDUCED COMA, THE VESTIBULO OCULAR REFLEX IS INTACT

CALORIC RESPONSE TEST

• WARM WATER (44 DEGREE C)

• COLD WATER ( 30 DEGREE C)

COWS

• COLD – OPPOSITE ( FAST COMPONENT)

• WARM – SAME SIDE (FAST COMPONENT)

•CALORIC RESPONSE ALSO TEST THE INTACTNESS OF VESTIBULO – OCULAR REFLEX

THANK U

• NEXT PPT – WILL BE LOCALISING THE LESION IN COMA