Modul Kuliah Pakar COMA (editted by HAE I).ppt

Modul Kuliah Pakar COMA (editted by HAE I).ppt

1. Dr. Moch. Dalhar, Sp.S
Dr. Farhad Bal’afif, SpBS
Dr. Achdiat Agoes, SpS
1
,

2. 2
Cerebral hemisphere
Diencefalon
Pons
Midbrain
Cerebellum
Medulla
Oblongata
Spinal cord
Cerebellar
Tentorii

3. CORTEX OF AWARENESS : Primary  Secondary  Tertiary
Somato-Sensoric Cortex
123  5  7

Visual
cortex
Auditory cortex
17  18  19

41  42  22

3

4. Cortex Of Awareness : Primary  Secondary Tertiary
28  35  25 34

Visual
cortex
17  18  19

Sensoric cortex
Olfactory cortex
123  5  7

4

5. 5
Reticulary System
in brain stem

6. 6
@ brain energy : - Glucose + Oxygen
@ brain weight 2 % of total body weight :
- CBF 15 % total Cardiac Output
- 20 % Oxygen demand
- 65 % Glucose demand
@ CBF Cortek : 80 – 100 ml/gr/mnt
CBF Sub cortek : 20 – 25 ml/gr/mnt
@ ANOXIA cell tolerance againts lack of O2 :
- Cardiac cell  30 minute
- Lung cell  2 hours
- Hepatic cell 1 – 2 hours
- Brain cell in a few minute
Central Nervous System

7. Central Nervous System
7

8. CONSCIOUSNESS
INPUT INTERGRATED
OUT PUT
Action Process Reaction
5 SENSES
• EYES
• EARS
• NOSE
• TONGUE
• SKIN
• Eye Opening
• Speech
• Movement
• Autonomic
AROUSAL
AWARENESS
LEVEL CONTENT/ QUALITY
Perception
(Gnosis)
Creativity
Sensation
Intention
Activity
Practice
Eloquent
ARAS
Specific
8

9. INPUT OF
CONSCIOUSNESS
SPESIFIC
NON SPESIFIC
Tongue
Medical
lemniscus
Solitary
nuclei.
Gustat Rad
5 SENSES Tract TerminalRadiatioCortex
Skin SpinoThalamik Thalamic Thal.Cortic
Area 123
Area 5 7
Eyes Optic TractC.Genic.Lat.Optic Rad
Area 17
Area 18 19
Ear
Lateral
lemniscus
C.Genic.Med
Acoustic
Rad
Area 41
Area 42 22
Nose Olfactory N
Olfactory
bulb
Olfact Stria
Area 28
Area 35 25
9

10. INPUT OF CONSCIOUSNESS
SENSORIS SKIN
SPESIFIC
Cortex
Thalamo-Cortical
Lat. Spinothalamic
Pain

Proprioseptif
Area 123
Thalamus
10

11. SENSORIC CONSCIOUSNESS (SKIN)
Primary cortex Area 123
Secondary cortex
Area 5
Tentiary cortex
Area 7
11

12. VISUAL INPUT
SPESIFIC

Retina
Optic Tract
Lat. genic body
Optic Radiatio
Primary cortex Area 17
Know
VISUAL CONSCIOUSNESS
Secondary cortex Area 18
Synthesis
Tertiary cortex Area 19
Understand / Analysis
12

13. AUDITORY CONSCIOUSNESS AUDITORIC INPUT
SPECIFIC
Labirinth Cohlea
Nn.VIII
Nuc.Nn.VIII
Medial Lemniscus
Primary Cortex Area 41
Know
Secondary Cortex Area 42
Synthesis
Tertiary Cortex Area 22
Analysis
13

14. INPUT CONSCIOUSNESS
SKIN SENSORIUM
NON SPECIFIC
Inter Neuron Network
TRIGGER OF CONSCIOUSNESS
CORTEX ON / OFF System
ARAS
A sending
R eticular
A ctivating
S ystem
14

15. IMPAIRED LEVEL OF CONSCIOUSNESS
1. Sensation from 5 Senses  Awareness
2. Reaction  • Eye Opening
• Speech
• Movement
1. Perception / Orientation
2. Creativity/ Thought / Reasoning
3. Sense/feeling
4. Intention/ Willingness
5. Activity / Psychomotor
II. Quality of Consciousness :
I. Level of Consciousness :
Agnostia
Amnesia
Aphractia
Aphasia
Psychiatry Neurology
15

16. QUALITY= CONTENT OF CONSCIOUSNESS
I. PERCEPTION:
1. Orientation: - People - Self - Time - Place
2. Gnosis : - Visual – Tactile - Auditory
- Taste - Scent
II. CREATION:
3. Memory : - Attention - Retention
- Counting - Recall - Knowledge
4. Thought / Imagination / Abstraction
5. Reasoning: - Similarity – Understanding - Judgment
- Comparison - Balancing
III. SENSE: 6. Affect and Emotion
IV. INTENTION: 7. Willingness = Desire – Appetite - Sex
V. ACTIVITY : 8. Psychomotor / Skill
9. Practice
10. Speech = Eloquent (Fluent)
16

17. IMPAIREMENT OF CONSCIOUSNESS QUALITY
OBS = Organic brain syndrome
Impairement of : 1. Power of consentration
2. Power of perception
3. Power of memory
4. Power of intelectual
5. Power of judgement, value
6. Power of self control
CLASIFICATION :
1. Global cognitive impairement : - Delirium Confusion State
- Demensia
- Amnesic Confusion State
2. Selective cognitive impairement : - Hallusination
- Frontal Lobe S
- Temporal Lobe S
3. Other mental disturbance : - Schizophren
- Paranoid state
- Depressive state
- Manic state
17

18. LEVEL OF CONSCIOUSNESS EXAMINATION
II. BRAIN STEM SCALE = ( PITTBURG ) P.B.S.S
1. Eyelash reflex 2 scores
2. Cornea reflex 2 scores
3. Light reflex D/S 4 scores
4. Doll eye / caloric test reflex 5 scores
5. Vomit reflex 2 scores

Total 15
I. GLASGOW COMA SCALE = G.C.S
1. Eye opening  4 scores
2. Speech  5 scores
3. Motorik  6 scores
18

19. G C S SCALE Lama
I. EYE OPENING SCORE
 Spontaneous 4
 To speech 3
 To pain 2
 None 1
II. VERBAL RESPONSE
 Orientated 5
 Confused 4
 Words 3
 Sound 2
 None 1
III. MOTOR RESPONSE
 Obeying command 6
 Localising 5
 Normal flexion 4
 Spastic flexion 3
 Extension 2
 None 1

• Compos Mentis
GCS : 15
• Somnolen
GCS : 12 – 14
• Stupor
GCS : 8 –11
• Sopor /
Semi Koma
GCS : 4 – 7
• Coma
GCS : 111 = 3
19

20. 14
20

21. Decorticate
Rigidity
Decerebrate –
Rigidity
21

22. CLASIFICATION OF COMA
A.Based on Topic of Lesion
I. Cortikal Bi Hemisphere coma
II. Diencephalic coma
B. Based on Anatomical Lesion :
I. Supra Tentorial Lesion
II. Infra Tentorial Lesion
C. Based on Etiology :
I. Neurological coma
II. Non neurological coma
/ Metabolic coma
/ Encephalopathy coma
22

23. CLASIFICATION OF COMA
I. Patophysiology + Anatomy
• Vascular general
• Hipoksia-anoksia
• Metabolit / Toxic
• Elektrolit
• High fever
• Ensefalitis /
Meningitis
1.Cortikal Bi Hemisphere coma:
 Functional disturbance
 Structural lesion
Ki Ka
23

24. 2.Diencephalic coma  Space occupying process
 Infratentorial
• CVA Bleeding
• Tumor
• Abscess
• Epidural hematoma
• Subdural hematoma
• Cerebral oedema
• Hydrocephalus
• Cerebral contusion
Impairement ARAS
3. ARAS Combination + Bihemisfer Cortex
 Supratentorial
24

25. 1. Hypoxia : < 12 ml / mnt / 100 gr
Anoxia
2. Hypoglicemia : < 31 – 46 Mgr %
3. Hyperglicemia : >1100 mg%
< 1,7-2,6 mol Tek.Osmose
4. Temperature : < 36
o
/ > 41
o
C
Anoxic
Anemic
5. Toxic material
@ DM Keton Bodies : Ketonuria + > 400 mg%
@ Uremia  NH
3
: > 5 - 6 X Normal
@ Acidosis : Ph < 7.0 / Alkalosis
@ Hipo / Hiper Na : < 126 mmol atau > 156 mmol
@ Vit B1 : < 100 g%
@ Toxin
6. Hipnotic : Barbiturate, Alcohol, Anestesia
7. Blood pressure / SHOCK : < 70 mmHg
8. Epilepsy
9. Infection
CORTICAL BI HEMISPHERE COMA
METABOLIC COMA / Encephalopathy
25

26. BRAIN ANOXIA
1. ANOXIC ANOXIA :
@ O2 Content
@ impairment of airway
@ Lung desease
@ CO2 Intoxication, Anestesia

2. ANEMIC ANOXIA :
@ Anemia
@ Hb content
@ Hypotension / Shock
@ Cardiac Arrest
3. HISTOTOXIC ANOXIA :
@ Intoxication: CO , Cyanida
26

27. SYNCOPE
Abrupt Loss of
Consciousness, Temporary
S irculation
PsYchiatry
N eurogenic
C ardiac
O rthostatic/Other
P osture
E xcretion
ABRUPT LOSS OF
CONSCIOUSNESS
1. EPILEPSY
2. CVA / STROKE
3. SYNCOPE
4. HYPOGLICEMIA
5. SHOCK
6. HISTERIA
27

28. SHOCK
Systemic failure of blood flow to the brain
With sign of hypotension
Causes:
1.Hypovolemic: @ Bleeding
@ Dehydration
2. Anafilactic : @ Allergy
3. Cardiogenic : @ Heart disease
4. Neurogenic : @ Severe pain
@ Vagal Reflex
@ Heat stroke
5. Septic : @ Systemic infection
6. Histeria
28

29. 1. COMA + FOCAL NEUROLOGICAL DEFICIT /
+ SIGNS OF LATERALIZATION
• Hemiparese/plegic
•Asymmetric Pupil
• Parese Cranial Nerves
• Asymmetric Reflexes
• Aphasia
• Rigidity
• Signs of Brain
Herniation
2. COMA + MENINGEAL SIGNS • Meningitis
+ ABNORMAL LIQUOR • CVA SAH ( Sub Arachnoid H )
+/- LATERALIZATION • Meningo-encephalitis
CLASSIFICATION OF COMA
• CVA
• Tumor
• Abscess
• Encephalitis
• Epi / Subdural B
• Contusio C
• Hydrocephalus
29
NEUROLOGIC
Coma

30. KLINIS:3. COMA + WITHOUT FOCAL NEUROLOGICAL DEFICIT /
+ WITHOUT SIGNS OF LATERALIZATION
+ WITHOUT MENINGEAL SIGNS
CLASSIFICATION OF COMA
• Uremia
• Hepaticum
• Ketoacidosis Diabetic
• Hypoglycemia
• Anoxia
• Syncope
• Shock
• Electrolyte imbalance
• Intoxication
30
Non Neurologic Coma
/ Metabolic Coma
/ Encephalopathy

31. 3. COMA + WITHOUT FOCAL NEUROLOGICAL DEFICIT /
+ WITHOUT SIGNS OF LATERALIZATION
+ WITHOUT MENINGEAL SIGNS
CLASSIFICATION OF COMA 30
C
I
M
E
N
T
E
D
Circulation, Cardiac
Infections : Encephalitis, Meningitis
Metabolic
Endocrine
Neurologic
Toxic
Excretion
Drugs

32. Space Occupying Process SUPRA TENTORIAL
Supra Tentorial  ARAS Disturbance
31
BRAIN HERNIATION
UNCAL Type
ARAS

33. Space Occupying Process SUPRA TENTORIAL
Supra Tentorial  ARAS Disturbance
32
BRAIN HERNIATION
Symmetrical
Central Type ARAS

34. Brainstem
33
ARAS

35. Alteration of Breathing PATTERN
BRAIN HERNIATION UNCAL Type
APNEA
34

36. Alteration of Pupil Pattern
BRAIN HERNIATION UNCAL Type
35

37. MUSCLE TONE PATTERN
BRAIN HERNIATION
UNCAL Type
Gegenhalten / Motor Negativism
FLACCID
Decerebrate Rigidity
Decorticate Rigidity
36

38. BRAIN HERNIATION PHASE of UNCAL Type  SUPRA TENTORIAL Lession
Examination Diensefalon
ConsciousnessStupor
Breathing Cheyne Stoke
Pulse Bradikardi
BP Normal
Temperature Normal
Ball Eyes Moving
Pupil Miosis
Refl. • Light
• Corneal
• Doll’s eye
+/+
+/+
+/+
Extremities
Decorticate
• Arms Flex
• Legs Exs
Med.
Oblongata
Coma
Apneustik
-


MPF
Midriasis
Rt/Lt
-/-
-/-
-/-
Flaccid
Atonic
Pons
Coma
Ataxia
Irregular
Hypertension
++++
Hyperthermia
MPF
Pin Point
-/-
-/-
-/-
Decerebrate
Mesencefalon
Semi Coma
Hyperventilatio
n
Bradicardia
Hypertension++
/
MPF
Asymmetric
Midriasis Ipsi.
+/-
+/+
+/+
Decerebrate
• Arms Ext
• Legs Ext
37

39. EXAMINATION FOR COMA
I. History taking: • Thorough Clinical
• Careful Topic
• Sistematic Etiology
II. Physical: • Head to toe - Resp
• Vital signs - Pulse
• Internal - Blood pressure
III. NEUROLOGIC:
1. Consciousness: • GCS • Brain Stem Reflexes Otak
2. Neuro Status : a. Neuro Fokal (+)
b. Meningeal Signs
c. Neuro Deficit Signs
d. Brain Herniation Signs
IV. SPECIAL EXAMINATION :
• Blod count/Urine analysis • ECG • LP
• Skull / Thorax X-ray
• Ophthalmoscopy  Oedema Papil
• Head CT scan • Arteriography
38

40. Reflex
Aferen
Nerve
Pusat
Eferen
Nerve
Light Reflex II CGL/ Mesen III
Eye brow R.
Corneal R.
V Pons VII
Doll’s Eye R.
Caloric R.
VIII Pons III VI
Gag Reflex IX Med.Oblo IX X
BRAIN STEM REFLEXES
39

41. Coma Pts
Basic life support
Breath Blood Brain Bladder Bowel
Meningeal
signs (+)
Focal
neurologic
signs (+)
Without
Focal neurologic
meningeal signs
40
- Right or left side limb weakness
- Asymitric pupil
- Asymetric reflex
- Focal / general seizure
- NN. Cranialis palsy

42. COMA Management
I.Basic Life Support
 Is a procedure of life saving
 In emergency room – immediate before
specialist intervention
 5B Principles : Breath Blood Brain Bladder Bowel
B1 BREATH:
1. Open and clean airway
2. Administer oxygen
3. If respiratory failure:
 Insert mayo tube or endotracheal intubation
 Oxygenation with bag valve mask
 Cardio pulmonanary resuscitation
4. Draw blood from artery  blood gas analysis
5. Chest X-ray if necessary
6. Continuous monitor : Frequency, rhythm,
breathlessness
41

43. B2 BLOOD
1. draw venous blood  check to lab
2. insert IV line  NaCl 0,9%
3. Maintain & monitor adequate “blood pressure &
pulse rate”
Dehydration  check plasma specific gravity 
correct deficit accordingly
hypotension  • IV Dopamine 3 gr/kg
 Drip 50 – 500 gr/500
4. ECG
42
 5B Principles : Breath Blood Brain Bladder Bowel

44. B3 BRAIN
1. Coma with unknown origin :
- Glucose 50% 50 cc IV
- Thiamine 100 mg IV
- Naloxone 0,6 – 0,8 mg IV
43
3.Sign of cerebral herniation / increased intracranial
pressure
• urgent consultation to neurology or neurosurgery
• Dexamethasone 10 mg IV, repeat 5 mg / 6 hours
• Drip IV Manitol 20 % 0,5 – 1 gr / KgBW
Drip 15 – 30 minutes, repeat every 4 hours
• + Furosemide 0,5 – 1 mg / Kg IV
2.Seizure
• Diazepam 10 mg IV repeat every 15 minute
• Phenytoin 10 – 18 mg/kg
50 mg / 100 cc NS  IV / Slow infusion
 5B Principles : Breath Blood Brain Bladder Bowel

45. 4.Head trauma :
• cranial AP / Lat / cranial base X-ray
• cervical vertebra AP / Lat / Obliq X-ray
• Dexametasone 4 x 5 mg / IV
• Piracetam
5.Neck stiffness  consult to neurology / LP
6.High fever  • IM Xylomidon
• tepid sponging
7.Anxious :• Diazepam 10 mg IV
• Chlorpromazine 25 mg / IM
 5B Principles : Breath Blood Brain Bladder Bowel 44
B3 BRAIN

46. B4 BLADDER:
1. insert dauer / folley catheter & Urobag
2. Collect urine specimen  cito lab
3. Monitor 24 hours urine collection
4. Attention to Fluid & electrolyte balance
 5B principles : Breath Blood Brain Bladder Bowel 45
B5 BOWEL
1. NGT insertion : commence on day 2
2. Alter position for every 2 hours
3. Caution : - Decubitus
- Hypostatic pneumonia
- Aspiration

47. Stroke Clinical Diagnosis Scale
Djoenaedi W Skor
1.TIA before onset of stroke 1
2.Onset :
•Very abrupt (1-2) minute
•Abrupt (few minute – hours)
•Slow - progressive
6,5
6,5
1
3.Activity during Onset:
• Work / activity
• Rest / sleep
• Wake up from sleep
6,5
1
1
4.Headache during onset:
• very severe
• severe
• slow (days)
• none
10
7,5
1
0
5.Vomit
• immediate on onset
• abrupt (minute – hours)
• none
10
7,5
0
Score
46

48. 6.Consciousness:
• loss of consciousness during onset
• loss of consciousness abruptly
• loss of consciousness slowly
• temporary loss of consciousness
• alert
10
10
1
1
0
7.Blood pressure:
• BP > 200/110 mmHg monthly during onset
• BP > 200/110 mmHg on hospitalization
• BP 140/110 – 200/110 mmHg monthly during
onset
• BP 140/110 – 200/110 mmHg on hospitalization
7,5
7,5
1
1
8.Meningeal signs:
• severe neck stiffness
• mild neck stiffness
• none
10
5
1
9.Fundus Oculi :
• Subhyaloid hemmorhage
• Retinal hemmorhage
• Normal
10
5
0
Stroke Clinical Diagnosis Scale
Djoenaedi W Skor
47

49. 10.Pupil :
• small + reactive
• small + sluggish reactive
• Midriasis Rt/Lt
• Pin Point Rt/Lt
• Asymetrical
• Isokor Normal
10
10
10
10
5
0
11. Blood count:
• Leucocyte > 10.00
• CPK increased
1
1
12. Fever :
• Fever < 1 hari
• Fever > 1 hari
1
1
TOTAL
SUMMARY:
• Score < 15 : Ischemic stroke
• Score >= 20 : Hemorrhagic stroke
• Score 15 – 19 : Uncertain
Sensitivity
• Hemorrhagic Stroke : 91,3%
• Ischemic Stroke : 82,4%
Stroke 87,5%
48

50. Meningeal Sign (+)
L P
Meningitis
Metabolic
CVA SAH
Abnormal Normal
49

51. FOCAL NEUROLOGIS (+)
With brain
Herniation process
Without brain
herniation process
CT Scan
Tumor (+) /
CVA ICH
Tumor (-)
CVA ICH (-)
Tumor
Abscess
Hydrochepalus
CVA
ICH
L P
CVA
Tombosit
Emboly
CVA
-Arteritis
-F. Steal
50

52. Without meningeal signs
Without focal neurologic signs
History taking
Specific lab examination
METABOLIC COMA
-Hypoglicemic
-Uremic – diabetic
-Hepatic
-Intoxication
-Contusion
-Encephalopathy
-Epilepsy
51

53. 52
DDx COMA

54. 53
DDx COMA

55. 54
DDx KOMA

56. 56
DDx COMA

57. 57DDx COMA

58. 57
DDx COMA

59. 57
DDx COMA

60. 57
DDx COMA

61. 58

62. 59
DDx COMA

63. 60
DDx COMA

64. 61
DDx
KCOMA

65. 62
DDx COMA

66. 63
DDx COMA