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Management of coma

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Page 1: Management of coma
Page 2: Management of coma

Why coma management?

• Common medical emergency 3-5%• Large proportion of comatose patient

recover• Untreated coma may lead to further

brain damage

Page 3: Management of coma

Check vital signs

• Respiration• Pulse, BP, • temperature.

Page 4: Management of coma

Emergency treatment

• Maintain ventilation oxygenation• Maintain circulation• Control seizure• Reduce icp• Maintain temperature• Control hypoglycemia

Page 5: Management of coma

Maintain ventilation

• Insert oral airway• Clean oropharyngeal secretion• Insert cuffed endotracheal tube if apnea,

hypoventilation or liable to aspirate• Mechanical ventilation if apnea or raised

intracranial pressure

Page 6: Management of coma

Draw Blood for

• Start venous line• Complete blood count, MP, B.sugar• Blood urea, s. creatinine,

s.electrolyte• Blood gases, ALT, AST• Give 25% 100ml glucose with

100mg of thiamine

Page 7: Management of coma

Maintain circulation

• If hypotenstion ( <90mmHg systolic)– Replace fluid:

• Saline if hyperglycemia or suspected stroke, diabetes

• Dextrose saline or isolyte if undiagnosed– Vasopressor if low systolic pressure inspite of

fluid• Hypertension: Betablocker, Nitroglycerine

or Nitropruside

Page 8: Management of coma

Control Seizure

• Inj Lorazepam 4mg or Midazolam 5mg IV slowly

• Inj Diazepam 10-20mg iv slowly• Inj Phenytoin 15-20mg/Kg 50mg/min IV• Inj Phenobarb 15-20mg/Kg 50mg/min IV• Inj Sodium valproate 200-400mg IV

Page 9: Management of coma

Reduce intracranial pressure

• Inj Mannitol 20% 1gm/kg IV fast

• Hyperventilatin to bring pCO2 25-30mmHg

Page 10: Management of coma

Maintain Temperature

• Hperthermia: tapid sponging, largectil,

• Hypothermia: heating blanket

Page 11: Management of coma

Is it Coma ?

• Posture: loss of erect posture

• Eye closed: sleep like state

• Lack of responsive ness

Page 12: Management of coma

Psychogenic coma

• Holds eye tight, resist opening• Fixed stare, quick blink• Normal pupil• Normal oculocephalic• Normal oculovestibular• Normal posture, breathing, bp,pulse

Page 13: Management of coma

Spectrum of Coma

• Psychogenic unresponsiveness• Acute confusional state• Locked in syndrome• Akinetic mutism• Persistent vegetative state• Brain death

Page 14: Management of coma

What causes coma?

Metabolic:-– Ischemic hypoxic– Hypoglycaemic– Organ failure– Electrolyte disturbance– Toxic

Structural:-– Supratentorial bilateral– Unilateral large lesion with transtentorial

herniation– Infratentorial

Page 15: Management of coma

Metabolic encephalopathy

• Confusional state -> coma • No focal neurological sign• No neck stiffness• Normal brainstem reflexes• Coarse tremor 8-10hz• Multifocal myoclonus

• Asterixis• Generalized/periodic myoclonus

Page 16: Management of coma

Supratentorial Lesions

• Epidural or Subdural Hematoma • Large Ischemic Infarction• Tumour• Intraparenchymal haemorrhage• Trauma• Abscess

Page 17: Management of coma

Infratentorial Lesions

• Basilar artery thrombosis• Pontine or Cerebellar Hematoma• Ischemic Cerebellar Infarction• Tumour• Abscess

Page 18: Management of coma

History

• Circumstances and temporal profile• Of the onset of coma• Details of preceding neurological• Symptoms headache, weakness seizure• Any fall• Use of drug and alcohol• Previous medical illness liver,kidney• Previous psychiatric illness

Page 19: Management of coma

Other symptoms of coma

• Yawning– Poor localizing value

– Posterior fossa expanding lesion

– Medial temporal, third ventricular

• Hiccup– Medullary lesion in the region of Third ventricle

• Vomiting– Lateral reticular formation of the medulla– Projectile ( usually nausea)– Medulloblastoma ependymoma– Raised icp -> compression of medulla– Basal meningitis– Ivh -> irritating fourth ventricle– Lateral medullary infarct (vestibular

Page 20: Management of coma

Examination

• General physical examination• Evidence of external injury• Colour of skin and mucosa• Odour of breath• Evidence of systemic illness• Heart lung

Page 21: Management of coma

Neurological examination

• Funduscopy• Pupil size and response to light• Ocular movements• Posture and limb movement• Reflexes

Page 22: Management of coma

Circulation

Kocher-Cushing response - rise in BP-

>bradycardia due to rise in ICP ->

compression of floor of the iv ventricle fall

in BP and tachycardia usually terminal

event due to medullary failure

Page 23: Management of coma

Breathing

• Forebrain– Post hyperventilation apnea– Cheyne stoke respiration

• Hypothalamus midbrain– Central neurogenic hyperventilation

• Basis pontis– Pseudobulbar paralysis of voluntary

center

Page 24: Management of coma

Breathing in coma

• Lower pontine tegmentum– Apneustic breathing– Cluster breathing– Short cycle periodic breathing– Ataxic breathing

• Medulla– Ataxic breathing– Slow regular respiration– Gasping

Page 25: Management of coma

Pupil

• Diencephalic (metabolic) Small reactive• Midbrain tectal Midsize,fixed• Midbrain nuclear Irregular pear shaped• 3rd nerve Fixed widely dilated• Pontine Pinpoint reactive• Opiate Pinpoint• Organophosphorus Small• Atropine Wide dilated

Page 26: Management of coma

Eye movement

• Metabolic – Roving eye movement,– Oculocephalic,– Vestibuloocular

• Supratentorial – Contralateral conjugate palsy

• Thalamus– Upper turn down

Page 27: Management of coma

Eye movements in Coma

• Midbrain– Ipsilateral 3rd

• Pontine– Ipsilateral 6th– Ipsilateral gaze palsy– One and half syndrome– Bilateral gaze palsy– Ocular bobbing– Mlf syndrome

Page 28: Management of coma

Posture

• Cerebral hemisphere – Decorticate posture

• Diencephalon supratentorial – Diagonal posture

• Upper brain stem – Decerebrate posture

• Pontine– Abnormal ext arm– Weak flexion leg

• Medullary– Flaccidity

Page 29: Management of coma

ECG changes in coma

(SAH, ICH, INFARCT)– Tall T, prolonged QT– Q wave with st depression– SVT, AF, AFL– Sinus bradycardia,arrest, nodal rhythm– A-V block or dissociation– PVc's, VFL, VF

Page 30: Management of coma

Further investigation

• CSF examination: neck stiffness without localizing sign

• CT scan/ MRI: Focal neurological sign or before LP

• X-ray chest: Aspiration, chest infection, heart size

• Ultrasound abdomen: Liver, kideny, bladder

Page 31: Management of coma

Agitated

1. Reassurance

2. Narcotics– Small doses administered– Intravenously

3. Sedation• Should follow analgesia• Sedation in presence of pain causes agitation,• Titrate intravenously so that agitation is blunted,• Do not induce excessive drowsiness

Page 32: Management of coma

Agitated patient

5. General management• Face a window for day/night orientation• Clock, calendar• Have friend or family member stay with patient• Light the room if illusions, paranoia occur at night• Provide eyeglasses, hearing aids• Have staff identify themselves to patient• Explain all procedures• Provide radio, reading, TV

Page 33: Management of coma

Coma Subsequent management

• Eye, mouth, skin• Fluid electrolyte, feeding• Respiration, circulation• Urine, bowel• Stimulation• Infection

Page 34: Management of coma

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