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Disorders of
Consciousness
Dr.Budhi Suwarma SpS
FK UNJANI
COMA and Related
Disorders of
Consciousness
3% of all admissions to the Emergency W.
Deep coma
Total lack of spontaneous movement
Total lack of motor and vocal rasponse
to all visual,auditory and cutaneous
stimulation
Spinal reflex may persist in some cases
Brain Death cont.
Absence of brainstem function
Absence of spontaneous eye movement
Mid position of the eyes
Lack of response to OC and OV testing
Fixed dilated / midposition fixed pupil
No facial movement and no gag, cough,
corneal, sucking reflex
Absence of decerebrate respons
No respiratory movement (PaC02 50-60)
Brain Death cont.
Most institutions demand proof of EEG (ECS,
flat, isoelectric, no wave > 2V during 30 min
recording)
Wait about 24 h before pronouncing the
patient death (6h massive cerebral
hemorrhage/trauma)
Exclude :
Profound hypothermia
Intoxication with hypnotic-sedative drugs
Immediately following cardiac arrest
Physiology and Morbid
anatomy of Coma
The state of consciousness depends on a
continuously active central generator (ARAS)
Sensory stimulation has a double effect
Convey information to the brain from somatic
structure and the environment
Activates ARAS
Cortex not only receives impuls from ARAS
but also modulates it via corticofu -gal
projection to centrencephalic
Disease mechanism that
disturb consciousness
Interfere metabolic activities of neuron
cortex (hypoxia,hypoglycemia,hyper/hypo-
osmoler,acidosis,alkalosis,hyperammonemi
a etc.)
Acute drop in CBF to 25 ml/min/100 gr
syncope ; 12-15 ml ECS coma.N(55)
CMR (metabolic encephalopathy)
O2 to 2 mg/min/100 gr (N=4)
Disease mechanism that
disturb consciousness
(cont.)
Body temperature > 41C or < 30C
DM : acetone bodies (acetoacetic acid,
-hydroxybutiric acid)
Uremia : phenolic derivates of the
aromatic amino acid
Hepatic coma : NH3 5-6 X N
Lactic acidosis : blood pH < 7
Pulmonary insufficiency : hypercapnia
Disease mechanism that
disturb consciousness
(cont.)
Hyponatremia < 120 mEq/L : water IC
General anesthetic,alcohol,opiates,pheny
toin,antidepressant,diazepines direct
effect on neuronal membrane,neurotrans-
mitter and their receptor
(cont.)
Subfalcial herniation : Paraparesis or tri
paresis, bilateral babinski signs
Ocular movement,eyelid,cornea
Choreic,athetotic,hemiballistic : disorder of
the basal ganglionic and subthalamic ncl
Postural changes in the
comatose patients
Decebrate rigidity : opisthotonus,clenching
of the jaws,stiff extension of the limbs,inter
nal rotation of the arm,plantar flexion of the
feet (transect intercollicular)