coma an d brainstem death powerpoint .pptx

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1. Coma and brainstem death Assoc Professor Datuk Dr S Nagappan ASDK;PGDK. MBBS;MD(Madras):MRCP(UK); FRCP( Lond );FRCP(Edin):FRCP( Irel );FAMM .

2. Objectives Coma: To differentiate between coma, brainstem death, minimally conscious state and persistent vegetative state. To know the pathophysiology of coma and list different causes. To be able to obtain a relevant clinical history related to the state of coma. To learn the approach and physical examination steps in a patient with coma. Brainstem Death To know the clinical assessment of brainstem death. To list investigation modalities for brainstem death assessment

3. 48 year old lady , mother of three children, developed sudden severe headache while washing clothes and vomitted a few times before collapsing on the bathroom floor. On arrival at AE, she was stuporous, only responding to painful stimulus. Her pulse was 94/ mt,with a BP of 220/160 mm of Hg. Her respiration was laborious and noisy and her pupils were unequal with left pupil in mid position and her right pupil small and reacting to light. Her eyes were deviated to the left side. Paucity of movements was noted on the right half of the body. History from the husband revealed that patient was diagnosed to have high BP 2years ago and was not taking regular treatment

4. Definition Definition

5. The Glasgow Coma Scale

6. Four scale F ull O utline of U n R esponsiveness scale

7. Pathophysiology ARAS

8. Anatomico-physiological approach

9. Supra tentorial Infra tentorial Metabolic

10. Focal cerebral dysfunction Herniation syndromes at some point 3 rd n palsy precedes coma sequential rostral to caudal deterioration of brain function Decerebrate posturing SS

11. Focal brainstem signs precede coma LOC abrupt or evolving pupillary abnormalities frequent, 3rd nerve palsy invariable Decorticate posturing

12. Metabolic Diffuse paratonic rigidity, astrixis,myoclonus ,seizures Gradual onset preceded by an acute confusional state Preservation of pupillary light reflex in the face of eyes that are immobile

13. Causes of coma Neurological Vascular Infectve Neoplastic Traumatic Epileptic Systemic Metabolic Endocrine and nutritional Toxins and drugs Sepsis Psychogenic

14. Approach to coma Resuscitation Ensure adequate oxygenation and airway protection Maintain perfusion pressure Check Blood glucose Temp Do ABG and check electrolytes Addl Therapeutic measures 25 ml of 50% dextrose ( Hypoglycaemia ) IV Thiamine (Alcoholism or malnutrition) IV Naloxine or Flumazenil (Narcotic or Diazepam overdose)

15. History Coma sequence, Headache and seizures Trauma Alcoholism and substance abuse Fever (infections) DM and HTN Poisoning Psychiatric history If a diabetic patient is found unconscious, treat as hypoglycaemia until otherwise. If a comatose patient is hypertensive, think of ICB first

16. General examination Skin –cherry red spot, rashes, sweating, needle marks, Pallor, cyanosis,jaundice Raccoon sign Battle sign

17. Observing the patient while lying Crucifix position – flaccid limbs spread eagled on the bed- deep coma Decorticate and Decerebrate postures Diagonal posture Paratonic rigidity Complex movements Multifocal seizures, myoclonus, asterixis-Metabolic Choreo athetotic and hemiballismic –Basal ganglia

18. Decerebrate rigidity Decorticate rigidity

19. Respiratory patterns Post hyperventilation apnoea - Forebrain Cheyne stokes breathing- waxing and weaning-interbrain Diencephalon Central neurogenic hyperventilation –Midbrain Apneustic breathing –Pons. Ataxic breathing ( Biot’s ) - Medulla

20. Eyes in coma Pupils Fundus Resting position Spontaneous movements Reflex movements

21. Eyes in Coma - PUPILS

22. Fundus Hemianopsia Papilledema Sub hyaloid hge Hypertensive encephalopathy

23. Eyes in coma –Resting position Eyes look toward a hemispheric lesion(away rom paralysis) and away from a brainstem lesion (towards the paralysis) Upward deviation Downward deviation- Hydrocephalus with dilatation of third ventricle Vertical separation-skew movement Down and in- Thalamic and upper midbrain lesions

24. Eyes in coma –Spontaneous eye movements

25. Eyes in coma –Reflex movements Doll’s eye phenomenon Caloric examination

26. Neurological examination- moor,sensory and reflex functions Hemiplegia and paucity of movements Appropriate and inappropriate movements Hemianaesthesia Tendon reflexes and plantar responses

27. Approach to coma Investigations Blood counts /blood film for MP Metabolic and endocrine panels Drug and alcohol screening Cxr and ECG LP and CSF analysis Brain imaging EEG

28. Brainstem death Cerebrum -Unarousable unconsciousness Midbrain - Fixed and dilated pupils Pons -Absent Doll’s eye henomenon Medulla - No spontaneous breathing Exclude hypothermia and sedative poisoning To be certified by two physicians

29. Pseudocoma states Persistent vegetative state Minimally conscious state Akinetic mutism and abulia Locked in syndrome Catatonia convesion syndrome

30. Persistent vegetative state Awake but not aware Persistent wakefulness without awareness

31. Locked in syndrome Locked-in syndrome  is a rare neurological disorder characterized by complete paralysis of voluntary muscles, except for those that control the eyes. People with  locked-in syndrome  are conscious and can think and reason but are unable to speak or move. Vertical eye movements and blinking can be used to communicate.

32. Akinetic mutism and abulia Akinetic mutism : A state in which a person is unable to speak (mute) or move (akinetic). ).

33. catatonia

34. Conversion reactions Conversion disorder, also known as functional neurological symptom disorder, occurs when a person experiences neurological symptoms (symptoms of the nervous system) not attributable to any medical condition. The symptoms are real and not imaginary, and they can affect motor functions and your senses.