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Coma. Peilin Lu Neurology Department SRRSH.

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slide1

Coma

Peilin Lu

Neurology Department SRRSH

slide2

A 32 year-old woman is found on the floor at work, unconscious, but spontaneously breathing. In the ER, BP is 146/75, pulse 80, afebrile. Her left pupil is 5 mm and sluggishly reacts to light; the right pupil is 2 mm and briskly reacts to light. She does not grimace or move to painful stimuli, nor attempt to speak.

slide3

What is the problem?

  • What can I do to make diagnosis?
  • How to check and treat?
definition
Definition
  • Coma
    • appears to be asleep
    • and incapable of being aroused by external stimuli or inner need
  • serious disturbance of consciousness.
arousal disorders
Arousal disorders
  • Disturbance of consciousness
    • waking disorder (Arousal disorder),
      • Drowsiness,
      • Lethargy
      • Coma
        • Light coma
        • Moderate coma
        • Deep coma
    • conscious content disturbance
drowsiness
Drowsiness
  • Drowsiness is the lightest kind of disturbance of consciousness,
  • continuous pathological sleep state,
  • patients can be woke up by mild stimulation and correctly answer questions or make various responses,
  • but go back to sleep soon after stimulation stopping.
lethargy
Lethargy
  • disturbance of conscious status whose awakening level is more severe than drowsiness,
  • may show a short awakening after strong or repetitive stimulation,
  • having no response or incorrect response to language,
  • falling into lethargy very soon once the stimulation is stopped.
slide8
Coma
    • a kind of severe disturbance of consciousness
    • appears to be asleep
    • incapable of being aroused by external stimuli or inner need
  • patients can not recognize themselves or the surrounding environment,
  • no eyes open movement and spontaneous language movement,
  • rare spontaneous limb movement
  • physiological reflex
    • normal, reduced or lost,
  • vital signs can be stable or unstable.
brain death
Brain death
  • over-coma.
  • irreversible brain damage
  • loss of whole brain function,
  • The termination of the cerebral circulation
  • The dysfunctional nervous system which can not maintain the stability of the body environment
disturbance of conscious content
Disturbance of conscious content
  • Confusion
    • mainly characterized by serious thought disorder, may be accompanied with disorientation, hallucinations, paranoia, anxiety, and so on.
delirium state
Delirium state
  • Also known as acute mental disorder state,
  • Appears as poor performance of arousal level, disorientation, lax attention, and serious disorders of many aspects such as perception, intelligence, emotion, and so on.
persistent vegetative state
Persistent vegetative state
  • A serious disturbance of consciousness
  • complete loss of perception, thought, emotion, memory, will and language activities,
  • No response to external stimulation and no limb spontaneous activities
altered states of consciousness
Altered states of consciousness:
  • Stupor
    • severely impaired arousal with some responsiveness to vigorous stimuli
spirit inhibiting status
Spirit inhibiting status
  • Common in hysteria or after severe mental trauma,
  • Patients lose their response to external stimulation suddenly,
  • May accompanied with fast breathing or breath holding,
  • Their eyes are closed or blinking rapidly,
  • Pupil light reflex are more sensitive,
  • Limbs are straight, buckling,
  • Neurological examination has no positive sign.
slide16

Locked-in syndrome

    • the losing of all other movement functions except eyes open, eyes close and eyes vertical movements, but the conscious is not affected.
anatomic basis of coma
Anatomic basis of coma.
  • Consciousness is maintained
  • by the normal functioning of
    • brainstem reticular activating system above the mid pons
    • and its bilateral projections to the thalamus and cerebral hemispheres.
  • Coma results from lesions that affect
    • either the reticular activating system
    • or both hemispheres.
  • The content of consciousness resides in the cerebral hemispheres;
causes of coma
Causes of coma
  • 1· Supratentorial mass lesions
  • 2· Infratentorial mass lesions
  • 3· Metabolic
history
History
  • Severe traumatic brain injury,
  • Poison taking,
  • Medication,
  • Happened in active state,
  • The suddenly happen of coma after a meal
environment factors
Environment factors
  • Common CO poisoning,
  • CO2 poisoning,
  • Chloride poisoning
  • Mostly caused by poor ventilation of living or working places of patients.
the changing process of symptoms
The changing process of symptoms
  • Coma after :
  • Fever
  • Severe headache
  • Precordial angina and profuse perspiration
concomitant symptoms
Concomitant symptoms
  • Coma accompanied with:
  • Hyperspasmia
  • Vomiting
  • Hemiplegic paralysis
  • Incontinence of urine and feces
  • Right upper abdominal pain,
  • Eyelid edema
  • Asthma and cyanosis
  • Extremely thin
past history
Past history
  • Injury happened in or longer than a week before coma,
  • Headaches, blurred vision and paroxysmal dementia,
  • Paroxysmal limbs convulsions, abnormal sensation or numbness
past history1
Past history
  • Hypertension
  • Liver disease
  • Diabetes mellitus,
  • Kidney disease,
past history2
Past history
  • Heart disease,
  • Lungs
  • Original infection
  • Original endocrine disease history
  • Tumor or cancer,
personal history
Personal history
  • Endemic areas living history
  • Toxic substances contacting history
  • Radioactive materials exposure history
  • Clues to the diagnosis of local and occupational diseases
  • Family history
  • Congenital or genetic disease.
signs
Signs
  • Basic vital signs
  • General physical checkup
  • The neurologic examination
basic vital signs
Basic vital signs
  • Breathing,
  • Body temperature,
  • Heart rate
  • Blood pressure.
breathing
Breathing
  • Respiratory rate
    • Normal : 14-20 times/min,
    • Bradypnea: <9 times/min
      • intracranial hypertension,
      • respiratory failure,
      • Slow and sighing like breath is mostly caused by morphine poisoning;
    • Tachypnea: >30 times/min,
      • acute infections
breathing manner
Breathing manner
  • Bilateral hemispheric or diencephalic damage: Cheyne-Stokes respirations (CSR) are a patter of periodic breathing in which phases of hyperpnea regularly alternate with apnea.
  • Of all the respiratory patterns listed, this has the least
  • specificity.   
hypothalamic midbrain damage
Hypothalamic-Midbrain damage
  • Central neurogenic hyperventilation is a sustained, rapid, and fairlydeep hyperpnea that often occurs in patients with dysfunction involving the rostral brainstem tegmentum.
pons damage
Pons damage
  • Apneustic breathing
  • prolonged inspiratory cramp
    • (a pause at full inspiration).
  • uncommon but localizes accurately to a lesion in the mid- or caudal-pontine level.       
medullary damage
Medullary damage
  • Ataxic breathing
  • (Biot’s respirations)
  • completely irregular and chaotic breathing pattern
  • deep and shallow breaths occur randomly.
  • The lesion involves the respiratory centers in the reticular formation of the medulla that control the normal to-and-fro pattern of breathing.
respiratory depth
Respiratory depth
  • Shallow and regular breathing
    • low blood sugar;
  • Snoring breathing accompanied by one side of facioplegia
    • cerebral hemorrhage;
  • Inspiratory phase > expiratory phase (stridulous breathing)
    • intra tracheal foreign body and severe laryngitis;
  • Inspiratory phase < expiratory phase
    • chronic obstructive pulmonary disease;
  • Fast, deep and regular breathing
    • diabetic ketone poisoning, uremia, sepsis, and poisoning by methanol, paraldehyde, vinylethyl alcohol and salicylates, often leading to respiratory alkalosis.
breath odor
Breath odor
  • uremia,
  • Diabetes
  • hydrocyanic acid poisoning
  • organophosphate poisoning
  • hepatic coma
  • excessive drinking
  • Ammonia smell breath -
  • Fruity breath -
  • Bitter almond smell breath -
  • The garlic smell breath -
  • Liver odor -
  • Alcoholic smell plus vomiting -
fever
Fever
  • Infection
  • Absorption of necrosis,
  • Intracranial infection,
  • Brain hemorrhage.
  • Fever accompanied with neck soft
    • cerebral malaria;
  • Fever accompanied with neck rigidity
    • meningitis,
    • encephalitis
    • subarachnoid hemorrhage.
slide39

Hypothermia

    • shock, hypoglycemia, poisoning and endocrine dysfunction.
  • Negative urine sugar accompanied with watery stool
    • cholera,
  • Positive urine sugar
    • diabetic coma.
heart rate
Heart rate
  • Accelerated heart rate
    • belladonna poisoning,
  • Fine and speed pulse
    • meningitis,
  • Slow and loud pulse
    • cerebral hemorrhage and alcoholism,
  • Slow and weak pulse
    • morphine poisoning..
blood pressure
Blood pressure
  • Low blood pressure is likely seen in myocardial infarction, pulmonary infarction, aneurysm rupture, post-traumatic entorrhagia and the late phase of severe intracranial hypertension,
  • High blood pressure is likely seen in hypertensive cerebral hemorrhage.
general inspection
General inspection:
  • Dry and burning heat skin -thermoplegia;
  • Moist skin -hypoglycemia, morphine poisoning, myocardial infarction and heatstroke;
  • Pallor -hypoglycemia and uremia;
  • Flushing -cerebral hemorrhage, alcoholism and belladonna poisoning;
  • Jaundice -hepatic coma;
  • Bleeding spots -epidemic cerebrospinal meningitis;
  • Roseola-typhoid fever.
slide44

Cherry red lips

    • carbon monoxide poisoning,
  • Cyanosis
    • hypoxic diseases such as heart insufficiency and pulmonary insufficiency,
  • Herpes
    • lobar pneumonia, meningococcal meningitis and viral infection which is accompanied with vivax malaria.
slide45

Panda eye signs such as bilateral periorbital blue,nose bleeding or bloodstain, occipital or postmastoidecchymosis,

basal skull fracture.

chest abdomen spine and limbs inspection
Chest, abdomen, spine and limbs inspection
  • Hemorrhagic shock
    • pneumohemothorax and abdominal internal haemorrhage,
  • Fat embolism
    • long bone fracture.
the neurologic examination
The neurologic examination
  • Mental Status Examination
    • language function
    • If no respond to verbal questioning, use painful stimulation (deep nailbed pressure, sternal rub, or a cotton swab inserted into the nasopharynx, etc)
pupils
Pupils
  • Pupillary size depend on the balance between
    • parasympathetic nervous system
      • (causing constriction via cranial nerve III)
    • the sympathetic nervous system
      • (causing dilation via the complicated sympathetic innervation of the pupil)
pupillary abnormalities
Pupillary abnormalities
  • ·Small pupils:
  • Bilateral small and fixed pupils
    • pressure transmitted to the pons ,
      • A hemorrhage within the pons, for example,
  • Only one pupil is small and associated with ptosis
    • (Horner’s syndrome),
large pupils
Large pupils
  •  Bilateral large pupils:
    • adrenergic stimulation
    • the stress of illness
    • in association with delirious states
    • drug withdrawals
    • epinephrine, atropine, and stimulant drugs (cocaine and PCP)
    • Central herniation through the tentorial notch results in bilateral third nerve palsies.
slide54

Ipsilateral large pupils:

    • ipsilateral 3rd nerve palsy
      • if a mass lesion with herniation causes the ipsilateraluncus to push the 3rd cranial nerve against the tentorium,.
    • A 3rd nerve palsy that came on suddenly in association with a headache would imply a posterior communicating aneurysm
eye movements
Eye movements
  • The oculocephalic (Doll's eyes) and oculovestibular (caloridtesting)
  • Doll's eyes phenomenon
    • when neck flexion, two eyelids are pulled up, two eyes open widely and two eyeballs turn to the upper side
fundus examination
Fundus examination
  • Papilledema is seen in intracranial space-occupying lesions;
  • Retinal exudation is seen in uremia;
  • Fundus hemorrhage is seen in subarachnoid hemorrhage or cerebral hemorrhage, and so on.
sensory
Sensory
  • Coma patient in light extent may have hypoalgesia and other superficial sense drops, and will show frown or defensive reflex such as avoidance to the pain stimuli;
  • For the coma patients in deep extent, all senses disappear completely.
movement
Movement
  • Movement inspection
    • muscle strength
    • muscle tone
    • involuntary movements
muscle strength
Muscle strength
  • Nervussupraorbitalis compression can be used to observe the corners of mouth and limbs movement,
  • Limbs dropping test can be used to confirm paralysis.
involuntary movements
Involuntary movements
  • Flapping tremor
    • hepatic coma or pulmonary encephalopathy;
  • Paroxysmal hyperspasmia
    • CO2, atropine or organic chlorine poisoning;
  • Tonic convulsion
    • CO, organic phosphorus, cyanide or strychnine poisoning;
  • Epileptic seizure
    • hematencephalon, craniocerebral injury;
  • Choreiform movements
    • rheumatic encephalopathy.
reflex
Reflex
  • Positive pathological reflexes
    • coma may caused by primary or secondary brain lesions,
  • Positive meningealirritatation sign
    • intracranial infection,
    • subarachnoid hemorrhage,
    • intracranial hypertension.
motor response
Motor response
  • Decortical posturing (flexed arms and extended legs)
    • a lesion at the level of the diencephalon or above.
  • Decerebrate posturing (extension of arms and legs due to overactivation of the lateral vestibulospinal tract) 
    • rostral brain stem lesions.
localization diagnosis
Localization diagnosis
  • The key organ that affecting the consciousness is brain,
  • The important organs that affecting the brain function are heart, lungs, liver, kidneys, pancreas, adrenal and blood system,
assistant examination
Assistant examination
  • Low hemoglobin concentration of blood (HCB)
    • anemia,
    • hemorrhagic shock;
  • Increased leukocyte
    • severe infection,
    • cerebral hemorrhage,
    • post-traumatic stress;
  • Decrease leukocyte
    • viral encephalitis,
    • viral meningitis,
    • typhoid.
positive urine glucose
Positive urine glucose
  • Positive urine glucose with positive ketones
    • diabetic ketoacidosis coma;
  • Positive urine glucose with negative ketones
    • diabetic lactic acidosis coma,
    • diabetic hyperosmoticnonketonic coma,
    • cerebral hemorrhage
urine test
Urine test
  • Positive urinary protein
    • uremia,
    • eclampsia accompanied with renal damage,
    • hypertensive encephalopathy,
    • cerebral hemorrhage
  • Positive urinary bilirubin and urobilin
    • hepatic coma,
    • acute infection accompanied with liver damage.
blood sugar
Blood sugar
  • Increased blood sugar
    • stress reaction
    • diabetic coma ,ketone bodies should be further test in order to confirm the cause of the diabetic coma;
  • Low blood sugar is common in severe liver damage, insulin shock or islet cell tumor, and so on.
slide71

Elevated blood ammonia

    • Hepatic coma (hepatic encephalopathy)
  • elevated blood ammonia accompanied with normal liver function,
    • Hashimoto encephalopa should be rule
lumbar puncture
Lumbar puncture
  • Bloody cerebrospinal fluid
    • all types of intracranial hemorrhage,
  • Increased neutrophil
    • intracranial bacterial purulent infection,
  • Increased lymphocytes
    • viral infection,
  • High content of sugar
    • diabetic,
  • lower content of sugar
    • intracranial infection and low blood sugar.
ecg and eeg
ECG and EEG
  • ECG
    • myocardial infarction,
    • arrhythmia and so on,
  • EEG
    • Most EEG pattern of coma patients is continuous δ wave;
    • Epilepsy
coma emergent care
Coma: emergent care
  • “A-B-Cs”
    • rule out primary cardiopulmonary cause
  • Immediately rule out hypoglycemia, or give 50% dextrose IV
  • Urgent brain CT
    • (rule out blood or edema) if head trauma or focal neuro deficit
  • Correct any hypothermia
  • Check metabolic panel, drug screens
coma emergent care headache fever stiff neck
Coma: emergent care---headache, fever, stiff neck
  • Urgent LP to rule out bacterial meningitis
  • If focal signs or papilledema, get brain CT first to verify abscess or other mass lesion
  • Empirical IV ceftriaxone & vancomycin (& ampicillin in older or debilitated adults)
  • If viral encephalitis suspected, get brain MRI, EEG, CSF PCR for Herpes simplex
coma cocktail
"Coma Cocktail"
  • The treatment of coma depends on the cause,
  • General treatment rules (if the cause is unknown):"coma cocktail"
    • thiamin (a vitamin that can help in alcoholic or nutritionally starved patients),
    • glucose (a sugar that can help diabetics who have developed a coma due to low sugar level),
    • naloxene (a substance that reverses the action of many narcotics and is used to treat overdoses).
slide79

Correcting for Electrolyte Imbalance or Toxic Substances

  • Decreasing Intracranial Pressure
    • hyperventilation,
    • Diuretics
    • surgery