COMA IN PATIENTS

(Level Of Conciousness)
Anwar Wardy W

Jakarta,June 2014
anwar wardy FKK UMJ
DOKTER DENGAN TINGKAT
KEMAMPUAN 3 A. SD 4
Mampu membuat diagnosis klinik
berdasarkan pemeriksaan fisik dan
pemeriksanaan tambahan yang diminta
(lab. Sederhana dan X- Rays
Dapat memutuskan dan memberi terapi
pendahuluan, serta merujuk ke spesialis
yang relevan (bukan kasus gawat darurat)

anwar wardy w fkk umj
DEFINITION
Coma is defined as a state of unresponsieness
and unconsciousness
Coma from the Greek word "koma,"
meaning deep sleep,
Coma can be a medical emergency
That requires intervention without always knowing
the cause
Knowledge of CNS anatomy can give clues to the
cause
anwar wardy FKK UMJ
ALTERED LEVEL OF
CONSCIOUNESS
Definition
Clouding of consciousness
Impaired capacity to think clearly and remember
current stimuli
Delirium -disturbed consciousness with motor
restlessness, disorientation and hallucination
Obtundation-reduced alertness, appears to be
sleep but responds to verbal or tactile stimuli
Stupor-reduced alertness, person only responds
to noxious stimuli
Coma-no response to noxious stimuli


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LETHARGY
Definition varies depending on the
source
Medical dictionaries define it
differently
Therefore it should probably not be
used by medical personnel.
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KEY TO DIAGNOSIS
A good history
A thorough physical exam
Knowledge of CNS anatomy
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GLASGOW COMA SCALE
Developed to define outcome in adult
patients with head injury
Coma: score of 8 or less
There is a modified scale used for infants
and children


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GLASGOW SCORE
Eye opening Motor Response
Spontaneous 4 obeys commands 6
To command 3 localizes pain 5
To pain 2 withdraws to pain 4
None 1 abnormal flexion 3
Verbal abnormal extension 2
Oriented 5 none 1
Confused 4
Inappropriate words 3 TOTAL 3-15
Incomprehensible sounds 2
None 1

anwar wardy FKK UMJ
MODIFIED GLASGOW COMA SCORE
For Infants
Eye opening Motor
spontaneous 4 normal 6
To speech 3 withdraws to touch 5
To pain 2 withdraws to pain 4
None 1 abnormal flexion 3
Verbal abnormal extension 2
Coos 4 none 1
Irritable cries 4
Cries to pain 3
Moans to pain 2
None 1
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GLASGOW COMA SCALE
A strong predictor of outcome
13: mild brain injury
9-12: Moderate brain injury
< 8: Severe brain injury (coma)
anwar wardy FKK UMJ
CAUSES OF IMPAIRED CONSCIOUSNESS
Metabolic/Toxic
Hypoxia-ischemia
Metabolic disorders-
Fluid and electrolyte imbalance
Hypertensive encephalopathy
Vitamin deficiency-thiamin, niacin, pyridoxine
Mitochondrial disorders
Toxins and poisons
infections


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POSSIBLE CAUSES
Alcohol
Epilepsy
Insulin
Overdose
Uremia (and other
metabolic causes)
Trauma
Infection
Psychiatric
Stroke, syncope
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STRUCTURAL/INTRINSIC
TRAUMA
NEOPLASMS
VASCULAR DISEASE
FOCAL INFECTION
HYDROCEPHALUS
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CSF PRODUCTION
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CSF Production
Produced in the ventricles by the choroid plexus by
ultra filtration of the plasma and carbonic anhydrase
catalyzed sodium potassium pump
Exits the ventricles via the foramina of Magendie and
Luschka
Enters subarchnoid space goes around the spinal cord
and brain.
CSF is reabsorbed by the arachnoid villi into the
saggital vein
Adult produces approximately 500 ml a day (20 ml/hr)
CSF volume at one time is approx 150 ml
Volume in the ventricles about 25 ml
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TYPES OF HYROCEPHALUS
Noncommunicating Hydrocephalus
Obstruction of CSF flow from ventricles to
the subarachnoid spaces
Communicating Hydrocephalus
No obstruction of ventricles - the problem is
either:
reabsorption of CSF by the arachnoid villi or
obstruction of saggital space
Overproduction of CSF in the choroid plexus
anwar wardy FKK UMJ
INFECTIOUS CAUSES OF COMA
Bacterial meningitis
Brain abscess
Epidural, subdural empyema
Fungal meningitis
Protozoan infections-amebic, malarial,
cysticercosis
Viral encephalitis
Postinfectious encephalomyelitis


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Acute Disseminated EncephaloMyelitis
(ADEM)
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ADEM
Immune-mediated disease of brain. It usually occurs
following a viral infection or vaccination, but it may
also appear spontaneously.
Abrupt onset and a monophasic course. Symptoms
usually begins 1-3 weeks after infection or
vaccination. Major symptoms are fever, headache,
drowsiness, seizures and coma.

Review: Pediatrics Aug 2002 110(2)
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FKK UMJ
BRAIN ABSCESS
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ENDOCRINE DISORDERS
Thyroid dysfunction
Adrenal insufficiency
Hypoparathyroidism
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HYPOXIA-ISCHEMIA
Shock
Cardiac or pulmonary failure
Near drowning
Carbon monoxide poisoning
Strangulation
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TRAUMA
Concussion
Cerebral contusion
Epidural hematoma
Subdural hematoma/effusion
Intracerebral hematoma
Diffuse axonal injury
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EPIDURAL HEMATOMA
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SUBDURAL HEMATOMA
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METABOLIC DISORDERS
Hypoglycemia
Acidosis
Hyperammonemia
Uremia


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GENERAL PHYSICAL EXAM
Vital signs
Temperature -fever (may mean infection)
Very high temperature and dry skin
consider heat stroke
Hypothermia often seen in drug
intoxication

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SKIN EXAMINATION
Cyanosis
Cherry red - carbon monoxide (almond odor)
Caf au lait spots - neurofibromatosis
Shagreen patches - tuberous sclerosis
Hyperpigmentation - Addison disease
Petechiae and purpura - meningococcemia
Signs of trauma suspicious bruises
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Pupillary response
pupillary constriction is controlled by the
parasympathetic system in the third nerve
Dilation mediated by the sympathetic
system hypothalamus to spinal cord and
then the superior cervical ganglia
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NEUROLOGIC EXAM
PUPILLARY REFLEX
Metabolic causes of coma
Can give a variety of changes but pupils
usually remain reactive
Drugs:
Narcotics-pinpoint but reactive
Atropine-dilated and nonreactive

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CORNEAL REFLEX
Test the fifth nerve sensory and seventh
nerve motor
Cotton on cornea and look for a blink or
watch the lower eyelashes move toward
the midline
Good test for mid and low pontine
dysfunction
Swab the nose to test seventh nerve
anwar wardy FKK UMJ
OCULOCEPHALIC REFLEX
Tests-sensory from the eighth nerve
Motor of the MLF 3
rd
, 4
th
6
th
nerves
Can only be done in patient with stable
spine
Turn the head quickly to the side and the
eyes should move to the opposite directions
of the movement
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COLD CALORIC RESPONSE
Oculovestiublar reflex
Tests the same pathway as dolls eyes but
can be done in patient with unstable cervical
cord.
Elevate the head 30 degrees place a catheter
in the ear and inject ice water.
In an awake patient: nystagmus
COWS: Cold water - fast component opposite and
warm water same side
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COLD CALORICS
When supratentorial disease develops
Due to metabolic depression of cortical
function - the fast component disappears and
the eyes move toward the cold water
stimulus
This reflex remains intact longer than the
dolls eyes reflex

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RESPIRATORY PATTERN
Injury location and type of breathing
Post hyperventilation apnea -bilateral
hemispheric dysfunction
Cheyne-stokes breathing
Central reflex hyperpnea- bilateral hemispheric
dysfunction injury to lower midbrain or upper
pons
Apneustic respiration- pons
Central Neurogenic Hyperventilation (formerly
known as Ondines curse) loss of involuntary
respiration- medulla
Apnea-medulla to C4, neuromuscular junction
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SIGNS OF COMA CAUSED BY STRUCTURAL
AND METABOLIC LESIONS
Supratentorial lesions
Initial focal signs
Retrocaudal progression
Neurologic examination is
asymmetrical

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UPPER MOTOR NEURON LESIONS
Cerebrum
Aphasia cortical sensory loss
Gaze preference
Nystagmus
Visual field deficit
Internal capsule
Equal paralysis of arm, legs, face
Motor loss without sensory loss
Motor loss with dense hemi sensory loss

anwar wardy FKK UMJ
UPPER MOTOR NEURON LESIONS
Midbrain-hemiplegia with contralateral 3rd
nerve palsy-Webers
Pons-Hemiplegia with contralateral 6th or 7th
palsy-Millard Gubler
Medulla-spastic weakness difficulty swallowing
Spinal cord -weakness of one with contralateral
loss of pain Brown-Sequard
OR paraplegia

anwar wardy FKK UMJ
INFRATENTORIAL LESIONS
Brainstem symptoms are often seen
initially
Sudden onset of coma
Cranial nerve abnormalities
Alteration of the respiratory pattern
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PROGRESSION OF MASS LESIONS
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TYPES OF BRAIN HERNIATIONS
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1= subfalcine
2 = uncus
3 = caudal
displacement
4 = cerebellar
tonsils
HERNIATION SYNDROMES
Tonsillar or Foramen Magnum Herniation
Displacement of brainstem and cerebellar tonsils into
the foramen magnum
Progressive ALOC, hypertension, bradycardia and irregular
respirations (Cushing Triad)
Transtentorial herniation
Displacement of medial aspect of temporal lobe into
tentorial hiatus
ALOC, ipsilaterial pupillary dilatation, contralateral
hemiparesis
Upward tentoral herniation
Cerebellar vermis moves into incisura
Produces brain stem compression

anwar wardy FKK UMJ
TOXIC, METABOLIC, INFECTIONS
Confusion and stupor often precede signs
Symmetrical examination
Pupillary reactions preserved
Respiratory pattern is often altered -
Cheyne-Stokes breathing

anwar wardy FKK UMJ
WORK UP FOR A PATIENT IN COMA
anwar wardy FKK UMJ
CONCLUSION
Poor sensitivity and specificity of physical
examination in predicting intracranial
injury on CT scan
Clinical examination has no diagnostic
value in predicting CT scan and should
not be used to determine whether CT
scans should be done or not.

anwar wardy FKK UMJ
MEDICAL INTERVENTION OF INCREASED ICP
Decrease CSF
Shunt fluid with external ventricultomy tube
Diamox 25-100 mg/kg/day in 3 doses
Reduce the size of other compartment
Mannitol or 3% NaCl
Mannitol 0.25 to 1.0 gm/ kg
Infuse over 10 to 15 minutes
Place foley
May need to provide NS bolus to maintain BP

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MANNITOL
Reduces ICP in two ways
Reduces blood viscosity and blood vessel
diameter decreases CPP maintained by
vasoconstriction so cerebral blood volume and
ICP decrease rapid but transient
Osmotic Effect
Developes more slowly (15-30minutes)
Water moves from parenchyma to blood
Lasts for up to 6 hours.


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3% Na Cl
Give as 5ml/kg bolus over an hour
Can be given in peripheral IV
Sodium movement across the blood brain
barrier is low.
Therefore works similar to Mannitol
Benefits may include:
Restore normal cellular resting membrane
potential
Stimulates atrial natriuretic peptide release
Inhibits inflammation




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3% NaCl
Possible side effects
Rebound increase of ICP when stopped
Central pontine myelinolysis
Subarachnoid hemorrhage
This has not been seen in studies of children

anwar wardy FKK UMJ
a2w@telkom.net FKK.UMJ.Juni 2008
TERIMA
KASIH,.Wassalam..//
Bahan Bacaan:
Gilroy John, Textbook Medical Neurology, MacMillan Publ.
co.Inc. 5
th
Edition London, 2009.
Surgery, and Internal Medicine, Neuroscience Intensive
Care Unit, 2006.
Epstein, Owen, Clinical Examination on Neurology
Emergency, Mosby 2005