ComaComa

A state of unarousable psychologic unresponsive-A state of unarousable psychologic unresponsive-ness in which the subjects lies with ness in which the subjects lies with eyes closedeyes closed

Coma vs. ConsciousnessComa vs. Consciousness Consciousness: wakefulness and responsivenessConsciousness: wakefulness and responsiveness The severity of coma is measured by comparing tThe severity of coma is measured by comparing t

he intensity of an external stimulus and the complhe intensity of an external stimulus and the complexity and purposefulness of the responseexity and purposefulness of the response

HypersomniaHypersomnia excessive drowsiness and excessive sleepexcessive drowsiness and excessive sleep narcolepsy, hypothalamic disorders, drugsnarcolepsy, hypothalamic disorders, drugs

Akinetic mutismAkinetic mutism silent, alert, and awake appearancesilent, alert, and awake appearance regular sleep-wake cyclesregular sleep-wake cycles no evidence of response to the environment, mno evidence of response to the environment, m

ental activities, or spontaneous movementsental activities, or spontaneous movements

Locked-in syndromeLocked-in syndrome total paralysis of all somatic musculaturetotal paralysis of all somatic musculature preserved consciousness and most sensory modalitiespreserved consciousness and most sensory modalities preserved vertical eye movementspreserved vertical eye movements ventral pontine infarctventral pontine infarct

Persistent vegetative statePersistent vegetative state preserved brainstem function, including breathingpreserved brainstem function, including breathing spontaneous eye opening and regular sleep-wake cyclespontaneous eye opening and regular sleep-wake cycle

ss no recognizable cognitive functionno recognizable cognitive function

Three categories of ComaThree categories of Coma

Diffuse brain dysfunctionDiffuse brain dysfunction matabolic encephalopathymatabolic encephalopathy drug intoxicationdrug intoxication

Primary brain stem disordersPrimary brain stem disorders brainstem strokebrainstem stroke brainstem neoplasm, absecessbrainstem neoplasm, absecess

Supratentorial mass lesionsSupratentorial mass lesions causing secondary brain stem compressioncausing secondary brain stem compression

Systemic evaluation of ComaSystemic evaluation of Coma

Is there systemic illness causing brain failure?Is there systemic illness causing brain failure?

Is there evidence of diffuse or focal brain injury?Is there evidence of diffuse or focal brain injury?

Is the patient improving or deteriorating?Is the patient improving or deteriorating?

Neurological examination in ComaNeurological examination in Coma

Response to external stimulationResponse to external stimulation

Motor responseMotor response

Size and reactivity of pupilsSize and reactivity of pupils

Eye movements and ocular reflexesEye movements and ocular reflexes

Pattern of breathingPattern of breathing

Response to external stimulationResponse to external stimulation

In order of In order of verbal commandverbal command, , shoutingshouting, , shakingshaking, , and and noxious stimulationnoxious stimulation

Localizing painLocalizing pain preserved brain stem function and intact connections preserved brain stem function and intact connections

to the appropriate cerebral hemisphereto the appropriate cerebral hemisphere Eye openingEye opening

preserved function of RASpreserved function of RAS

Motor responsesMotor responses Absence of any motor responseAbsence of any motor response

severe brain stem damagesevere brain stem damage severe sedative drug ingestionsevere sedative drug ingestion

Decorticate, flexor posturing of the armsDecorticate, flexor posturing of the arms bilateral cerebral hemisphere damagebilateral cerebral hemisphere damage toxic/metabolic encephalopathytoxic/metabolic encephalopathy

Decerebrate, extensor posturing of the armsDecerebrate, extensor posturing of the arms destructive lesions of the midbrain and upper ponsdestructive lesions of the midbrain and upper pons hepatic and anoxic-ischemic encephalopathyhepatic and anoxic-ischemic encephalopathy

Pupillary responsesPupillary responses Small, reactive pupilsSmall, reactive pupils

metabolicmetabolic IICP with hypothalamic dysfunctionIICP with hypothalamic dysfunction

Very small pupils (pinpoint)Very small pupils (pinpoint) pontine lesionpontine lesion narcotic (opioids) overdosenarcotic (opioids) overdose

Bilateral dilated fixed pupilsBilateral dilated fixed pupils seizure, anoxic encephalopathyseizure, anoxic encephalopathy exogenous catecholamimesexogenous catecholamimes

Pupillary responsesPupillary responses

Midposition and fixed pupilsMidposition and fixed pupils midbrain dysfunctionmidbrain dysfunction brain deathbrain death

Unilateral dilated pupilUnilateral dilated pupil damage to IIIrd nerve from trnastentorial herniationdamage to IIIrd nerve from trnastentorial herniation

Eye movementsEye movements

Spontaneous roving, horizontal and conjugate eye Spontaneous roving, horizontal and conjugate eye movementsmovements intact brain stemintact brain stem diffuse or metabolic cortical dysfunctiondiffuse or metabolic cortical dysfunction

Conjugate lateral deviationConjugate lateral deviation massive hemispheric lesion (eyes toward lesion)massive hemispheric lesion (eyes toward lesion) pontine lesion (eyes away from lesion)pontine lesion (eyes away from lesion)

Eye movementsEye movements

Doll’s eyes reflexDoll’s eyes reflex intact brainstem function with depressed cortical influintact brainstem function with depressed cortical influ

encesences normal sleep, coma, persistent vegetative statenormal sleep, coma, persistent vegetative state

Ice water caloric testIce water caloric test eyes toward the side of cold watereyes toward the side of cold water absence in brainstem lesion, inner ear disease, deep drabsence in brainstem lesion, inner ear disease, deep dr

ug coma, and anticonvulsants overdoseug coma, and anticonvulsants overdose

Pattern of breathingPattern of breathing

Cheyne-Stokes respirationCheyne-Stokes respiration Central neurogenic hyperventilationCentral neurogenic hyperventilation Apneustic breathingApneustic breathing Irregular periodic breathingIrregular periodic breathing Ataxic breathingAtaxic breathing YawningYawning

Cheyne-Stokes respirationCheyne-Stokes respiration

Periodic breathing, crescendo-decrescendoPeriodic breathing, crescendo-decrescendo The result of the loss of frontal lobe controlsThe result of the loss of frontal lobe controls Blood PCO2 drives brain stem respiratory centerBlood PCO2 drives brain stem respiratory center Posthyperventilation apneaPosthyperventilation apnea CausesCauses

Frontal lobe damage, unilateral or bilateralFrontal lobe damage, unilateral or bilateral Secondary to cardiac or respiratory failureSecondary to cardiac or respiratory failure

Central neurogenic hyperventilationCentral neurogenic hyperventilation

Sustained, rapid, deep hyperpneaSustained, rapid, deep hyperpnea NotNot secondary to hypoxemia and acidemia secondary to hypoxemia and acidemia CausesCauses

Upper brain stem lesionUpper brain stem lesion Metabolic disorders, especially the early stages of hepMetabolic disorders, especially the early stages of hep

atic coma atic coma

Apneustic breathingApneustic breathing

Prolonged inspiratory gaspProlonged inspiratory gasp Discrete lesions of the mid-to-lower ponsDiscrete lesions of the mid-to-lower pons Need early intubation and ventilationNeed early intubation and ventilation CausesCauses

pontine infarctpontine infarct hypoglycemia, anoxia, or severe meningitishypoglycemia, anoxia, or severe meningitis

Ataxic and irregular periodic breathingAtaxic and irregular periodic breathing Completely irregular patternCompletely irregular pattern Slow and progressed to apneaSlow and progressed to apnea Respiratory center - dorsomedial medullaRespiratory center - dorsomedial medulla Terminal statesTerminal states CausesCauses

posterior fossa lesionsposterior fossa lesions medullary damagemedullary damage overdoses of opiate and sedativesoverdoses of opiate and sedatives

Differential diagnosis of ComaDifferential diagnosis of Coma

Metabolic and toxic causesMetabolic and toxic causes presence of pupillary light reflexpresence of pupillary light reflex confusion and stupor precedesconfusion and stupor precedes symmetric motor signssymmetric motor signs asterixis, myoclonus, tremor, seizures (generalized)asterixis, myoclonus, tremor, seizures (generalized) central hyperventilationcentral hyperventilation

Differential diagnosis of ComaDifferential diagnosis of Coma Supratentorial mass lesionsSupratentorial mass lesions

focal neurologic singsfocal neurologic sings progresses in a rostral-caudal fasionprogresses in a rostral-caudal fasion

Subtentorial masses or destructive lesionsSubtentorial masses or destructive lesions sudden onset of comasudden onset of coma history of brain stem dysfunction (the 6 D’s)history of brain stem dysfunction (the 6 D’s) abnormal eye movementsabnormal eye movements cranial palsiescranial palsies irregular respirationirregular respiration

Diagnostic proceduresDiagnostic procedures Metabolic or toxic causesMetabolic or toxic causes

blood, urine, gastric aspirates testingblood, urine, gastric aspirates testing EEGEEG

Intracranial mass lesions, head injuryIntracranial mass lesions, head injury CTCT

Acute subarachnoid or intracerebral hemorrhageAcute subarachnoid or intracerebral hemorrhage CTCT lumbar punctureslumbar punctures

Meningitis or encephalitisMeningitis or encephalitis lumbar punctureslumbar punctures

Treatment of ComaTreatment of Coma Immediate treatment, even when the diagnosis is Immediate treatment, even when the diagnosis is

uncertain, to prevent further brain damageuncertain, to prevent further brain damage Oxygenation and airway protectionOxygenation and airway protection

ET tubeET tube ventilationventilation

Blood pressures maintainBlood pressures maintain volume replacement with isotonic solutionsvolume replacement with isotonic solutions hemodynamic monitoringhemodynamic monitoring inotropic and vasopressor drugsinotropic and vasopressor drugs

Treatment of ComaTreatment of Coma

GlucoseGlucose (50 mL of 50% glucose) (50 mL of 50% glucose) ThiameThiame (100 mg, with the glucose) (100 mg, with the glucose) Seizures stopSeizures stop Intracranial hypertension lowerIntracranial hypertension lower Systemic infections controlSystemic infections control Acid-base and electrolytes imbalances correctAcid-base and electrolytes imbalances correct Hyperthermia treatHyperthermia treat

Prognosis: Prognosis: Hypoxic-ischemic encephalopathyHypoxic-ischemic encephalopathy

1st day: absence of pupillary responses predicts p1st day: absence of pupillary responses predicts poor outcomeoor outcome

2nd day: no patients lack corneal reflex regained 2nd day: no patients lack corneal reflex regained consciousnessconsciousness

After 3rd day: lack or purposeful motor responses After 3rd day: lack or purposeful motor responses predict poor outcomepredict poor outcome

Persistent Vegetative State (PVS)Persistent Vegetative State (PVS)

A form of eyes-open permanent unconsciousness.A form of eyes-open permanent unconsciousness.

Periods of wakefulness and physiologic Periods of wakefulness and physiologic sleep/wake cycles.sleep/wake cycles.

Unaware of self or environment.Unaware of self or environment.

Persistent Vegetative State (PVS)Persistent Vegetative State (PVS)

No voluntary action or behavior. Only primitive rNo voluntary action or behavior. Only primitive reflexes and vegetative functions.eflexes and vegetative functions.

Careful and extended clinical observation, supporCareful and extended clinical observation, supported by laboratory studies.ted by laboratory studies.

In cases of hypoxic-ischemic encephalopathy, obsIn cases of hypoxic-ischemic encephalopathy, observation period of one to three months.ervation period of one to three months.

Prolonged survival.Prolonged survival. No pain or suffering.No pain or suffering.

Neurological criteria for DeathNeurological criteria for Death

The Uniform Determination of Death Acts:The Uniform Determination of Death Acts: irreversible cessation of circulatory and respiratory irreversible cessation of circulatory and respiratory

functions, orfunctions, or irreversible cessation of all functions of the entire irreversible cessation of all functions of the entire

brain, including the brain stembrain, including the brain stem The determination of death must be made in The determination of death must be made in

accordance with accepted medical standardsaccordance with accepted medical standards

Diagnosis of Death by neurologic criteriaDiagnosis of Death by neurologic criteria

A A clinicalclinical diagnosis, with preconditions and confi diagnosis, with preconditions and confirmatory testsrmatory tests

The core of the clinical diagnosis is to establish uThe core of the clinical diagnosis is to establish unresponsiveness and brain stem areflexianresponsiveness and brain stem areflexia

The preconditionsThe preconditions the cause of coma be knownthe cause of coma be known the cause be adequate to explain the comathe cause be adequate to explain the coma

腦死判定程序 腦死判定程序 76.9.17.76.9.17. 衛生署醫字第衛生署醫字第 688301688301 號公告號公告

僅適用於人體器官移植之特定範圍僅適用於人體器官移植之特定範圍 判定前之先決條件判定前之先決條件

深度昏迷，不能自行呼吸深度昏迷，不能自行呼吸 導致昏迷的原因已確定導致昏迷的原因已確定 無法復原之腦部結構損壞無法復原之腦部結構損壞

排除可逆性昏迷排除可逆性昏迷 如新陳代謝障礙、藥物中毒與低體溫導致之昏迷如新陳代謝障礙、藥物中毒與低體溫導致之昏迷 罹病原因不明，即應排除罹病原因不明，即應排除

使用人工呼吸器，至少觀察使用人工呼吸器，至少觀察 1212 小時小時

腦死判定程序 腦死判定程序 - - 臨床檢視臨床檢視

確認無下列徵象確認無下列徵象 自發性呼吸自發性呼吸 異常姿勢，如去皮質或去大腦之姿勢異常姿勢，如去皮質或去大腦之姿勢 癲癇性抽搐癲癇性抽搐

腦死判定程序 腦死判定程序 - - 腦幹功能測試腦幹功能測試

確認腦幹反射消失確認腦幹反射消失 頭、眼反射頭、眼反射 瞳孔對光反射瞳孔對光反射 眼角膜反射眼角膜反射 前庭、動眼反射前庭、動眼反射 對身體任何部位之疼痛刺激、在顱神經分佈區範圍對身體任何部位之疼痛刺激、在顱神經分佈區範圍內，不能引起運動反應內，不能引起運動反應

以導管在氣管抽痰時，不能引起作嘔咳嗽之反射以導管在氣管抽痰時，不能引起作嘔咳嗽之反射

腦死判定程序 腦死判定程序 - - 測試無自行呼吸 測試無自行呼吸 (Apnea test)(Apnea test)

由人工呼吸器供應由人工呼吸器供應 100%100% 氧氣氧氣 1010 分鐘分鐘 給予給予 95%95% 氧氣加氧氣加 5%5% 二氧化碳二氧化碳 55 分鐘使動脈血中分鐘使動脈血中 PaCPaC

OO22 達到達到 40 mmHg40 mmHg 以上以上 取除人工呼吸器，並由氣管內管供應取除人工呼吸器，並由氣管內管供應 100%100% 氧氣，每氧氣，每

分鐘分鐘 66 公升公升 觀察觀察 1010 分鐘，並測最後血中分鐘，並測最後血中 PaCOPaCO22 濃度濃度 確認病人無法自行呼吸確認病人無法自行呼吸

腦死判定程序 腦死判定程序 - - 第二次測試第二次測試

第一次測試完畢後至少四小時後為之第一次測試完畢後至少四小時後為之 腦死判定，經第二次測試，如病人仍完全符合腦死判定，經第二次測試，如病人仍完全符合

無腦幹反射與不能自行呼吸之條件，即可判定無腦幹反射與不能自行呼吸之條件，即可判定病人腦死病人腦死