medicine.Coma managment.(dr.muhamad tahir)

ΔMSΔMS

Ken Uchino, M.D.

Assistant Professor of Neurology

UPMC Stroke Institute

DEFINITIONDEFINITIONCOMA: the complete absence of

awareness of self and the environment even when the subject is externally stimulated

ΔΔMSMS

ConfusionConfusionDrowsyDrowsy—Inability to sustain wakefulness —Inability to sustain wakefulness

without external stimuliwithout external stimuliObtundationObtundation—aroused by vigorous stimuli, —aroused by vigorous stimuli,

interacts brieflyinteracts brieflyStuporStupor—arounsed only by vigorous and repated —arounsed only by vigorous and repated

stimuli, but not interactivestimuli, but not interactiveComaComa

ΔΔMSMS IT’S A SPECTRUM:

ALERT ”DROWSY” ”OBTUNDED” ”STUPOROUS” COMATOSE

….much better to just describe what you see!

ANATOMYANATOMYRETICULAR ACTIVATING SYSTEM:

– a primitive, evolutionarily conserved diffuse (reticular) network of neurons throughout the brain

– some more concentrated areas “nuclei” or “centers”

– originates in brainstem– ascends through diencephalon via which it

connects to rest of brain

ANATOMYANATOMYTwo major anatomic patterns of coma:

1. Diffuse cerebral injury (2/3)

or

2. Focal injury to the brainstem (1/3)

DIFFUSE CEREBRAL DIFFUSE CEREBRAL INJURYINJURY

TraumaTrauma– Concussion, diffuse axonal injuryConcussion, diffuse axonal injury

VascularVascular– Global hypoxia-ischemiaGlobal hypoxia-ischemia– Hypertensive encephalopathyHypertensive encephalopathy

InfectiousInfectious– SepsisSepsis– Meningitis, encephalitisMeningitis, encephalitis

EpilepticEpileptic– Post-ictal statePost-ictal state– Non-convulsive status epilepticusNon-convulsive status epilepticus

DIFFUSE CEREBRAL DIFFUSE CEREBRAL INJURYINJURY

Metabolic:Metabolic:– Electrolyte abnormalities:Electrolyte abnormalities:

pH disturbancepH disturbance Hyper or hyponatremiaHyper or hyponatremia Hyper or hypoglycemiaHyper or hypoglycemia Hyper or hypocalcemiaHyper or hypocalcemia

– Organ failureOrgan failure liver, kidneyliver, kidney

– Thiamine or vitamin B12 deficiencyThiamine or vitamin B12 deficiency– Drug intoxication or withdrawalDrug intoxication or withdrawal

FOCAL BRAINSTEM INJURYFOCAL BRAINSTEM INJURY

Direct hit to the brainstem– Brainstem stroke or tumor

Secondary pressure onto the brainstem– Trauma

Subdural or epidural hematoma

– Vascular Subarachnoid hemorrhage Intracerebral hemorrhage

– Neoplasm– The mass raises intracranial pressure and herniation onto

the brainstem.

Case 1Case 1

50 yo man sent confused from homeless shelter.

History not obtainable. ? EtOH abusePE: Afebrile, tachycardic. Mildy

hypertensive. Really groggy. When aroused, very

confused, dysarthric.

Case 1Case 1

CT normalLabs: WBC 15, otherwise CBC, Chem 7,

LFTs normal. EtOH level undetcable, Urine tox: negative for drugs of abuse.

Presumed dx: toxic encephalopathy, EtOH withdrawal

Case1Case1

Febrile in the evening. The resident attempts to perform LP.After attempt at decubitous position…Attempted sitting up (with help of nurse and

attending physician)…Green fluid comes out.

ΔMS H&PΔMS H&P 1. Recent events:

– When was the patient last seen?– How was the patient discovered?– Were there any preceding neurologic complaints?– Was there any recent trauma or toxic exposure?

2. Medical istory 3. Psychiatric history 4. Medications 5. Use of drugs or alcohol

General Physical ExamGeneral Physical Exam

Vitals– Is there a fever?– Severe hypertension?

Skin– Trauma, jaundice, needle marks

Head– Fractures, lacerations

Neck (do not manipulate if suspect Fx!)– Stiffness?

Neurologic exam…

Coma examComa exam

Describe:Observe then stimulate:

– Level of consciousness

Brain stem Exam– Fundi, Pupils, Corneals, EOM, Gag and cough

Extremities

Coma Exam: Level of Coma Exam: Level of ConsciousnessConsciousness

Awake “Opens eyes to voice,” “grimaces to pain,”… Localizes pain—pain where ?(central vs. peripheral) Any abnormal response? Patterned response?

– Flexor posturing (Decorticate)– Extensor posturing (Decerebrate)– Myoclonus?

Respiratory pattern? – “Riding the vent” vs. overbreathing

RespirationRespirationCheyne- Stokes pattern

– diencephalic/ diffuse– CHF

hyperventilation– midbrain

apneustic pattern– pons

ataxic respiration– medulla

…interesting, but not really useful in the field!

Testing LOCTesting LOC

First, First, a verbal command:a verbal command:– Specific command (hard): “Show me two Specific command (hard): “Show me two

fingers!” fingers!” not “squeeze my hand”not “squeeze my hand”

– Midline command (easier): “Open your eyes”Midline command (easier): “Open your eyes” eye lid apraxia? eye lid apraxia?

Try it again with a Try it again with a noxious stimulusnoxious stimulus

Testing LOC: Noxious Testing LOC: Noxious stimulusstimulus

– Head: Head: ear pinch,ear pinch, cotton swab to nares, supraorbirtal ridge pressure, pin to nares cotton swab to nares, supraorbirtal ridge pressure, pin to nares

– BodyBody Sternal rub, shoulder pinchSternal rub, shoulder pinch AreolaAreolapossibly the most sensitive spot you can find…It also helps you possibly the most sensitive spot you can find…It also helps you

identify the malingering patients.identify the malingering patients.

– ExtremitiesExtremities Pinch arm or calf, Nailbed pressure, plantar stimulationPinch arm or calf, Nailbed pressure, plantar stimulation

ResponseResponse LocalizationLocalization WithdawalWithdawal Flexor (decorticate) posturingFlexor (decorticate) posturing Extensor (decerebrate) posturingExtensor (decerebrate) posturing

PosturingPosturing Extensor posturing (Decerebrate)

– Hips and shoulders extend, adduct, and internally rotate – Knees and elbows extend – Forearms hyperpronate, Wrists and fingers flex – Feet plantar flex and invert – Trunk extends, Head retracts

Flexor posturing (Decorticate)– Shoulders adduct, internally rotate, and flex slightly; elbows

flex; forearms pronate; and wrists and fingers flex – Lower extremities extend, adduct, and internally rotate – Hip, knee, and ankle may flex in a spinal reflex known as triple

flexion

A picture speaks…A picture speaks…

• It means that the It means that the patient is not patient is not conscious. conscious.

• The cortex isn’t The cortex isn’t communicating. communicating.

• It’s not well It’s not well localizing. localizing.

Brains stem reflexes: pupilsBrains stem reflexes: pupilscritical in distinguishing metabolic from

structural etiologies of coma

Brainstem reflexes: pupilsBrainstem reflexes: pupils

Dilated, unreactive pupils – third nerve compression– sympathetic agonist drugs (cocaine)– cholinergic antagonists (atropine)

Small reactive pupils +/- Horner’s syndrome– hypothalamus/diencephalon injury– damage to sympathetic input – opiates, cholinergic agonist drugs

Brainstem reflexes: pupilsBrainstem reflexes: pupils

fixed midposition pupils– midbrain– i.e. loss of sympathetic and para- sympathetic

inputs (Edinger- Westphal)

small unreactive/ minimally reactive pupils– pons, cholinergic poisoning

Brain stem reflexes: Brain stem reflexes: extraocular movementsextraocular movements

Horizontal conjugate gaze is mediated by:

– Frontal eye fields– Pontine gaze centers

In unresponsive patients, conjugate eye movments can be elicited by:– Oculocephalic reflex (Doll’s eye)– Oculovestibular reflex (Cold water calorics)

Brain stem reflexes: EOMBrain stem reflexes: EOM

First, observe at rest– Roving – Not moving– Gaze deviation

Hemispheric lesion: “eyes look at the lesion”

Pontine damage: “eyes look away from the lesion”

Seizure: “eyes look away from the lesion.”

Brainstem reflexes: EOMBrainstem reflexes: EOM

Conjugate– A good sign, but do they move appropriately?

Dysconjugate– A bad sign, but why?

Just relaxed muscles? Impaired EOM?

Brainstem reflexes: EOMBrainstem reflexes: EOM

Next, try the reflexes:1. Oculocephalic (aka Doll’s eye) reflex:

– Presence indicates that the brainstem is intact

2. Coculovestibular (caloric) reflex:– Tonic deviation towards the cold ear

Brainstem reflexesBrainstem reflexes Corneal Reflexes:Corneal Reflexes:

– CN 5 & 7CN 5 & 7– pontine lesionpontine lesion

Gag Reflex:Gag Reflex:– afferent componentafferent component

IXIX– efferent componentefferent component

XX

Brainstem reflexesBrainstem reflexes Pupils: Pupils:

– II in– III out

EOM: – VIII in – III, (IV), VI out

Corneals: Corneals: – V in – VII out

Gag: – IX in– X out

EYE

ExtremitiesExtremities

Reflexes– Deep tendon reflexes– Response to noxious stimuli:

Is it a reflex or withdrawal? Plantar response—triple flexion

Glasgow Coma ScaleGlasgow Coma ScaleEye OpeningEye OpeningNoneNone 11

To PainTo Pain 22

To SpeechTo Speech 33

SpontaneousSpontaneous 44Best Verbal ResponseBest Verbal ResponseNoneNone 11

Incomprehensible soundsIncomprehensible sounds 22

Inappropriate wordsInappropriate words 33

ConfusedConfused 44

OrientedOriented 55

Best Motor ResponseBest Motor ResponseNoneNone 11

Extension (at elbow)Extension (at elbow) 22

Abnormal FlexionAbnormal Flexion 33

WithdrawalWithdrawal 44

Localizes pain (attempts to Localizes pain (attempts to remove stimulus)remove stimulus)

55

Obeys commands (simple Obeys commands (simple commands)commands)

66

Total Score = 3-15Total Score = 3-15

Case 2 (JJ)Case 2 (JJ)

78 yo woman stopped talking and had right sided weakness.

On the way to the hospital, she vomited. Became unresponsive.

PMH: macular degeneration, anxiety. Pt was intubated in the ER. Received lasix

for HTN of 218/98.

BP 180/90 P 84 afebrile General PE: unremarkable, except intubated. Neurologic: No spontaneous movements or eye

opening. Not following commands. Noxious stimuli:

– She localizes pain in the left UE. She has purposeful movement in the left upper extremity (squeezing hand sponaten.).

– On the right side, extensor posturing to pain on the right UE and triple flexion in the right lower extremity.

Brain stem: – Her pupils are 2 mm and reactive. She has left gaze

preference, but has spontaneous eye movements. Visual field is difficult to assess. She has gag reflex intact.

CATEGORIZECATEGORIZE

Nonfocal exam with brainstem intactNonfocal exam with brainstem intact– Reactive pupils, full eye movements, symmetric motor Reactive pupils, full eye movements, symmetric motor

responses.responses.– Suggests diffuse cerebral damage.Suggests diffuse cerebral damage.

Focal hemispheric signsFocal hemispheric signs– Contralateral hemiparesis, gaze paresisContralateral hemiparesis, gaze paresis– Suggests structural CNS lesionSuggests structural CNS lesion

Focal brain stem signsFocal brain stem signs– Abnormal pupil reactivity, cranial nerve signs, motor Abnormal pupil reactivity, cranial nerve signs, motor

posturing.posturing.– Suggests brainstem lesionSuggests brainstem lesion

MANAGEMENTMANAGEMENT

In the case of a diffuse cerebral injury with no known cause…give the coma “cocktail”:– THIAMINE 100 mg IV– 50% DEXTROSE 50ml IV– NALOXONE (Narcan) 0.4-0.8 mg IV– (FLUMAZENIL (Romazicon) 0.2-1.0 mg IV)

MANAGEMENTMANAGEMENT

In the case of focal hemispheric or brainstem signs, obtain neuroimaging..– CT– MRI

And look for signs of increased intracranial pressure

Case 3 (CM)Case 3 (CM) 75 yo F found down by husband. 75 yo F found down by husband. She has left hemiparesis, dysarthric. C/o HA. She has left hemiparesis, dysarthric. C/o HA. PMH: GERD, no HTNPMH: GERD, no HTN SH: Husband: she drinks and smokes as much as she can. SH: Husband: she drinks and smokes as much as she can. PE: BP 106/90PE: BP 106/90 A+O x3. Follows commands. Speech fluent, but dysarthric. She A+O x3. Follows commands. Speech fluent, but dysarthric. She

has left neglect. has left neglect. Pupils 6Pupils 63 mm. Left VF cut. Corneal and gag reflexes present. 3 mm. Left VF cut. Corneal and gag reflexes present.

Facial sensation is diminished on the left. Right eyelid droop Facial sensation is diminished on the left. Right eyelid droop (old). (old).

Flaccid hemiplegia. Sensation: neglect. Deep tendon reflexes 1 Flaccid hemiplegia. Sensation: neglect. Deep tendon reflexes 1 throughout. Toes going up bilaterally. throughout. Toes going up bilaterally.

Right thalamic ICH & IVHRight thalamic ICH & IVHCT: on Nov 5 at 1450

Case 3Case 3Day 2Day 2

BP 169/94No eye opening to stimuli. Not following

commands. Eyes downward and to the left. Pupils 3mm

reactive. Corneal reflexes present. Left hemiplegic. RUE purposeful

movement. RLE withdrawal. Bilateral upgoing toes.

ICH & hydrocephalusICH & hydrocephalus• CT: Nov 6 at

4:50 am• Subsequently

Intubated• Ventriculostomy


ICP shot up early morning. Got head CT: Exam off propofol x 5min: LUE extension and RUE flexion to pain

centrally as well as peripherally. Triple flexion in LE bilaterally. Pupils 2mm reactive. Left gaze deviation

but some spontaneous roving movements. Corneal reflex intact.


Off propofol for 24 hoursBP 148/68 P 120 RR 14/13Unresponsive to sound or painPupils fixed at 4mm, corneal reflexes

present. Absent gag reflex. Triple flexion in LE. Pt expired later that day.

Herniation SyndromesHerniation SyndromesCentral TranstentorialCentral Transtentorial

– paratonic rigidity of lower extremitiesparatonic rigidity of lower extremities– pinpoint pupils (sometimes)pinpoint pupils (sometimes)– hyperreflexia/ spontaneous triple flexion responseshyperreflexia/ spontaneous triple flexion responses– waning level of consciousnesswaning level of consciousness– sudden cardiac or respiratory arrest/ deathsudden cardiac or respiratory arrest/ death

Herniation SyndromesHerniation Syndromes

Herniation SyndromesHerniation SyndromesLateral Transtentorial/Uncal:Lateral Transtentorial/Uncal:

– most common in those with temporal lobe most common in those with temporal lobe masses (tumor, hematoma,…)masses (tumor, hematoma,…)

– ipsilateral dilated pupilipsilateral dilated pupilthen bilateralthen bilateral– hyperreflexia/ spasticityhyperreflexia/ spasticity– ipsilateral hemiplegia (Kernohan’s notch)ipsilateral hemiplegia (Kernohan’s notch)– hemianopsia (PCA infarct)hemianopsia (PCA infarct)– brainstem compression/ deathbrainstem compression/ death

Herniation SyndromesHerniation Syndromes SUBFALCIAL HERNIATION

– ipsilateral and/or contralateral paratonic rigidity

– LE paralysis (once completed)– akinetic mutism (bilateral ACA)

TONSILLAR HERNIATION– downward cerebellar herniation– nausea, vomiting, hyperreflexia– sudden respiratory arrest

Herniation SyndromesHerniation SyndromesUpward cerebellar herniation:

– nausea, vomiting, hyperreflexia– SCA infarction syndrome– hyperventilation– brainstem compression/ coma/ death

Transcranial Hernation:– skull fracture, craniotomy– ischemia of adjacent cortex (strangulation)

Case 4Case 4

35 yo man unresponsive. Pt was just booked for some incident. At

police station, found with empty pill bottle. Pt unresponsive. No known medical history.

Case 4Case 4

CT head normal Labs:

– Urine tox for drugs of abuse normal (opiates, amphetamines, cocaine, tricyclics), salicylate and acetaminophen levels undetectable.

PE: – Vitals normal– General exam: shackled to stretcher

Blood in back

– Unresponsive to voice, pain. Brainstem reflexes intact. Extremity reflexes in tact.

TechniquesTechniques

Let arm drop on faceTickle naresSurprise the patient

Case 4Case 4

Wouldn’t let eyes be openedER residents had attempted LP without

lidocaine. (The blood in back).He only flinches with needle in his back. I further macerate his back and succeed in

getting CSF—normalAngry man next morning.

Case 5Case 5

40 yo woman from rural Washington statePresents to local ER c/o “throat swelling.”

She also c/o blurred vision. The exam is reported to be fairly unremarkable initially. But in the ER she worsens and develops respiratory arrest.

No signficant past medical history. No asthma or allergies.

Case 5Case 5

She is intubated, given steroids for presumed allergic reaction or angioedema. She is transferred to Seattle.

In medical ICU she is on vent. She is treated for aspiration pneumonia, reactive airways. She remains unresponsive. Comatose. Never wakes up.

Several days later neurology is consulted for post-anoxic encephalopathy. Is she going to wake up?

Case 5Case 5

Exam: Vitals normal. Riding the vent. – Unresponsive to pain, sound. – Pupils unreactive, absent corneals, cold calorics

absent, no gag. Areflexic in extremities

CT of head: normal. Is she brain dead?

Brain Death:Brain Death: the complete and irreversible cessation of all

brain function absent pupillary responses (fixed,

midposition) absent oculocephalic responses absent corneals, gag absent calorics response absent motor response absent respiration (pCO2>60)

APNEA TEST– preoxygenate with 100% O2– maintain O2 through ETT with cannula etc.– two minute duration– pCO2 of 60mmHg or higher adequate

COLD WATER CALORICS– never do in a noncomatose person– ice water 30cc to each ear– wait 2 minutes for response before other side

Brain Death: Brain Death: Necessary TestsNecessary Tests

Case 5Case 5

Wait, she moves her toe!

Brain Death: Brain Death: PitfallsPitfalls

no drugs or hypothermia to explain a precondition of diagnosis

absent pupillary responses– anticholinergic drugs, especially atropine in

cardiac arrest– NM blockade– preexisting eye disease

absent oculocephalics– ototoxic/ vestibular toxins

Brain Death: Brain Death: PitfallsPitfalls

apnea– NM blockade– post- hyperventilation– phrenic nerve palsies/ diaphragm paralysis

no motor activity– NM blockade– locked in syndrome– sedatives

Brain Death: Brain Death: Confirmatory TestsConfirmatory Tests

Confirmatory tests are NOT necessary for the diagnosis. Tests necessary if the checklist incomplete.

– Trauma, hemodynamic instabilityTests:

– EEG with special array, sensitivity settings ICU artifact can create problems

– cerebral blood flow (Nuc Med) – Transcranial Doppler ultrasound– Evoked potential studies

not legally required to render futile care to a dead person

SummarySummary

Get good History from surrogateExamineIs it focal or diffuse?

medicine.Coma managment.(dr.muhamad tahir)

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Transcript of medicine.Coma managment.(dr.muhamad tahir)