Acute coma

Unconsciousness , Disturbance of con

sciousness

Degression of level of consciousness

Deep inhibitory state of higher nervo

us activity

DefinitionDefinition

Mechanism

Consciousness ① Level of awareness of brain

② Sensation, Perception

Himself , Enviroment

③ Responsiveness

Inner need, External stimulation

④ Expressed

language, Body movement, Behavior

Composition of consciousness Cognition Contents ： Orientation, Perceptivity, Attention, Remembranc

e, Affection, Thinking and Behavior

Expressed ： Language,Body movement and behavior

Controlled ： Cerebral cortex

Waking state

Controlled

Ascending reticular activating system in b

rainstem ( ARAS )

Function

Special sensory conduction →

Unspecial nerve corpuscle in thalamus →

All cerebral cortex

Etiology and pathology

Disturbance

① Cerebral cortex

② Ascending reticular activating sys

tem in brainstem or thalamus

Feature of Ascending reticular activating system

① Thin nerve fiber

② Longer transmiting distance

③ More times for neurone to be exchange

④ Influenced easily by enviroment and drug

Disturbance of consciousness in level

Coma, Confusion

Special kinds of disturbance of consciousne

ss

Dementia, lapsus memoriae

Clinical classificatioClinical classificationn

Somnolence Stupor Light coma Deep coma

Arousal + + - -

Orientation + - - -Go with examination + - - -

Reaction to stimuli + + + -

Spontaneous action + + + -

Brainstem reflexes + + +- -

Babinski sign + + +- -

Vital sign stable Stable stable unstable

Clinical classification of unconsciousness

Confusion Confusion DeliriumDelirium

Somnolence + +

IrritationIrritation -- ++

Orientation + -

AttenuationAttenuation -- --

Delusion + +

IllusionIllusion +-+- ++

Insight + -

Change in Change in autonomic nerveautonomic nerve

++ ++

Special group of disturbance of consciousnessSpecial group of disturbance of consciousness

Glassgow coma scaleEye Verbal Motor Scores

Obeys commands 6

Orientated Localises pain 5

Eyes openingspontaneously confused

Withdraws from pain 4

Eye opening tospeech

Inappropriate words

Flexion to pain (Decorticate) 3

Eye opening to pain

Incomprehe-nsible sounds

Extension to pain (Decerebrate) 2

No eye openingNo verbal

responseNo motor

response 1

Special groups of conscious disturbance

— coma vigil

1) Open and close eyes

2) Chew and swallow

3) Sleep-wake cycles

Decorticate syndrome

1) Arms flex ， leg straighten

2) Higher muscular tension

3) Babinski sign

4) Cerebral cortex is damaged

Decerebrate syndrom 1) Four limbs straighten

2) Higher muscular tension

3) Babinski sign

4) All brain is damaged

Akinetic mutism

1) Muscle relaxation ，

2) No babinski sign

3) Ascending reticular activating system in brainstem or thalamus is damaged

Differential diagnosis

Persistent vegetative state

1) “Unconscious and unaware”

2) Exhibit sleep-wake cycles

3) Grinding teeth, swallowing, smiling, shedding tears, grunting, moaning, or screaming

4) Heads and eyes can track moving objects or

turn towards a sound

5) An impaired connectivity between the

brainstem, thalamus and the cortex

6) The general brain activity in the cortex is

lower in the PVS state.

Brain death

Complete and irreversible cessation of brain

activity (cerebral, brain stem , cerebellum)

Criteria

1) Deep coma

2) No spontaneous respiration

3) No response to pain, no cranial nerve reflexe

s

4) Spinal reflex may persist

5) EEG: flat or isoelectric 24h

6) Exclude for intoxication, hypothermia, meta

bolic disturbance or persistent vegetative st

ate

Hysteria

Syncope

1. Transient loss of consciousness and posture

2. A global reduction in blood flow to the brain

Locked-in syndrome

A lesion of the ventral pons..

1) Alert

2) Unable to response with speech or facial or li

mb movements

3) Vertical eye movements and blinking

Abulia

A lesion of both lobus frontalis

Serious Apathy

Stuporous state

Stupor syndrom

A rough response ( like screaming ) to a

noxious stimulus

Etiology Central nervous system diseases

Cerebrovascular disease Cerebral thrombosis Cerebral embolism Cerebral hemorrhage Subarachnoid hemorrhage

Headtrauma

Seizure

Inflammation

Encephalitis, meningitis, cerebral abscess

Tumor

Hypoxia Heart -- Cardiac output ↓

Heart failure, Asystole, tachycardia, br

adycardia

Lung -- pO2 ↓, pCO2↑, acidosis

COPD, pneumonia, pneumonedma pul

monary infarction, drowing

Liver--hepatic coma

Serious hepatitis,hepatonecrosis

hepatic cirrhosis

Kidney—Uremia

Acidosis, ion disturbance or cerebral edema af

ter dialysis

Metabolic abnormalities Hypoglycemia, hyperglycemia,Ketoacidosis, hyperosmosis ， lactic acidosis hyperthyroidism crisis ， Addison‘s diseasesheehan syndrome

Electrolyte disturbances

Low sodium, low chlorine, water intoxication

Intoxication

Drug ：

Benzodiazepine, barbiturates, anti

psychotic drug

Insecticide ： Organophosphorus ， pyrethroid

carbamate pesticide ， weed killer

Other intoxicant

Alcohol, Carbon Monoxide, Orga

nic solvent, poisnous vapor

Physical examination

General examinationGeneral examination TemperatureTemperature

T↑ ： Inflamation, central high fever

heat stroke

T↓ ： Shock, hypoglycaemia, Hypnotic intoxication

Arterial pulse

p ↓ ： Sinus bradycardia, atrial ventricul

ar block(A-VB) ,intracranial hypertension

p↑ ： Hyperpyrexia, hyperthyreosis conge

stive heart failure, shock supraventricular tach

ycardia

Breath Rhythm Rhythm Cheyne-Stokes breathing

---- A lesion of Cerebral hemishere Central neuro-hyperventilation

---- A lesion of midbrain Ataxia breathing

---- A lesion of bulbus medullae

Smell

---- Rotten apple, garlic, alcohol, amonia, hepatic odor

Blood pressure

BP↑ ： hypertensive encephalopathy, CH

BP↓ ： shock

Skin and membrana mucosa

Jaundice, bleeding point, ecchymosis,

Sweat, cyanosis, flush

Cranal trauma

Raccon eyes, Battlesign ，leakage of cerebrospinal fluid

Meningeal irritation sign

Kernig sign or brudzinski sign

Examination in internal medicine Heart, lung, liver, kidney, etc.

Neurologic check Eyes sign Pupil

One dilatation ： Cerebral hernia

Both dilatation ： Atropine poisoning Both diminution: Organophosphate ， morphine

Hypnotic ， hypoglycaemia A lesion of brainstem

Eyeball position

FixationFixation ：：Divergence: cerebellumDivergence: cerebellum

Side-glanceSide-glance ：：

Lesion of Lesion of side glance centreside glance centre （ （ cerebcerebral hemisphere or pons ral hemisphere or pons ） ）

Fasciculus longitudinalis medialiFasciculus longitudinalis mediali

Eye ground

Bleeding

Vitreous hemorrhage

Angiosclerosis,

Papilledema

Pain recationLocating

Decorticate rigidity ( thalamus or cerebral

hemisphere ),

Decerebrate rigidity (midbrain)

Assessment Degree of coma

Palsy sign

Hemiplegia, Babinski sign

Brainstem function

Corneal reflex

Oculovestibular reflex

Oculocephalic reflex (Dull head test)

Auxiliary examination

• CT, MRI , EEG , examination of cerebr

ospinal fluid

• Po2, Pco2, HCO3, BE , CoHb, Hemiglob

in, Choline esterase (CHE)

GPT,GPT,GOT, GOT, Blood ammonia , BUN Cr, Blood ammonia , BUN Cr,

Ion, Blood glucoseIon, Blood glucose Detecting intoxicant or productDetecting intoxicant or product of of

metabolismmetabolism

Diagnosis

History+Physical sign + Auxiliary examination

Onset ： environment, process, time degree of urgency, motivation, etc.

Main symptom and concomitant symptom

Age, season, past history

Treatment Symptomatic treatment

1) Monitor: ECG, BP, Consciousness, pupil

pulse, pulse, respiration , etc.

2) Open respiratory tract

3) Balance water , electrolytes and acid-base.

4) Relieve and prevent cerebral edema

20% manital, complexglycerine, furose

mide , 50%Glucose, Albumin, etc.

5) Protection for cerebral function

Radical scavenger ： barbiturate, VC,VE Opiate receptor blocking pharmacon: Narcon Ca2+ receptor blocking pharmacon Nimodipi

ne , Flunarizine , etc.

6) Hypothermy, Hibernotherapy:

Tympanic temperature: 33~35℃

Etiological treatment

Prevent complication

Aspirated pneumonia,

Urinary system infection,

Bedsore,

Disturbance of Water-Electrolyte （ Hyponatremi

a ）

Acid- base balance