Brain Failure

8/7/2019 Brain Failure

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Brain failureBrain failure


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KOMAKOMA

Berasal dari kata Yunani = tidur yang dalBerasal dari kata Yunani = tidur yang dal

Manifestasi gagal otak paling beratManifestasi gagal otak paling berat

Penurunan tingkat kesadaran paling rendPenurunan tingkat kesadaran paling rend


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KESADARANKESADARAN

Awake/arousal (bangun) :Awake/arousal (bangun) :

ReticularActivating System (RAS)ReticularActivating System (RAS)MedullaMedullaCentral MOCentral MO----ThalamusThalamusCortexCortex

Bentuk kesadaran paling primitifBentuk kesadaran paling primitif

Awareness (

waspada) : Cortex

Awareness (

waspada) : Cortex


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TingkatTingkatKesadaranKesadaran

Compos MentisCompos Mentis

Obtundasi (apatis)Obtundasi (apatis)Letargik (somnolen)Letargik (somnolen)

Stupor (sopor)Stupor (sopor)

VegetatifVegetatifKomaKoma

AwakeAwake

(+)(+)


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StructuralStructural

Trauma, Intracranial haemorrhage, Brain abscess,Trauma, Intracranial haemorrhage, Brain abscess,

NeoplasmsNeoplasms

CerebroCerebro--vascular accident, Cerebral venous sinusvascular accident, Cerebral venous sinus

thrombosis, Infarctthrombosis, Infarct

Metabolic (encephalopathy)Metabolic (encephalopathy)Infection, Meningitis, Encephalitis, Cerebral Malaria,Infection, Meningitis, Encephalitis, Cerebral Malaria,

Poisoning, Hypoxia, Hypercarbia, Metabolic acidosis,Poisoning, Hypoxia, Hypercarbia, Metabolic acidosis,

Hyponatremia, Hypoglycemia, Congestive heart failure,Hyponatremia, Hypoglycemia, Congestive heart failure,

Shock, Cyanotic spell, Diabetic ketoacidosis, InsulinShock, Cyanotic spell, Diabetic ketoacidosis, Insulin

dependent diabetes mellitus, Hypopituitarism,dependent diabetes mellitus, Hypopituitarism,

Hypothyroidism, Renal failure, Liver failure, Hypothermia,Hypothyroidism, Renal failure, Liver failure, Hypothermia,

Heat stroke, Epilepsy, convulsion, InbornHeat stroke, Epilepsy, convulsion, Inborn--errors oferrors of

metabolismmetabolism

Psychiatric (?)Psychiatric (?)

EtiologyEtiology


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Unconscious ?Unconscious ?

How deeply ?How deeply ?

ICP raised ?ICP raised ?Emergency management ?Emergency management ?

Management of unconscious child ?Management of unconscious child ?

Prognosis?Prognosis?


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Glasgow Coma Scale (Teasdale and Jennet)Glasgow Coma Scale (Teasdale and Jennet)

Modified Glasgow Coma Scale (James and Trauner)Modified Glasgow Coma Scale (James and Trauner) Children's Coma Score (Raimondi and Hirschauer)Children's Coma Score (Raimondi and Hirschauer)

Adelaide Paediatric Coma Scale (Simpson and Reilly)Adelaide Paediatric Coma Scale (Simpson and Reilly)

Seshia scaleSeshia scale

Scoring systemScoring system


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Modified Glasgow Coma Scale (James and Trauner, 1985)Modified Glasgow Coma Scale (James and Trauner, 1985)

ActivityActivity

EyeEye--openingopening

VerbalVerbal

MotorMotor

>5 years>5 years

SpontaneousSpontaneousTo voiceTo voice

To painTo pain

NoneNone

OrientatedOrientated

ConfusedConfusedInappropriate wordsInappropriate words

Incomprehensible soundsIncomprehensible sounds

No response to painNo response to pain

Obeys commandsObeys commands

Localises to supraocular painLocalises to supraocular pain

Withdraws nailbed pressureWithdraws nailbed pressure

Flexion to supraocular painFlexion to supraocular pain

Extension to supraocular painExtension to supraocular pain

No responseNo response

ScoreScore

4433

22

11

55

4433

22

11

66

55

44

33

22

11


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Children's Coma ScoreChildren's Coma Score(Raimondi and Hirschauer)(Raimondi and Hirschauer)

EOM = Extra ocular muscles; Total = (Maximum score assignable is 11, minimal 3)EOM = Extra ocular muscles; Total = (Maximum score assignable is 11, minimal 3)Reference : Raimondi AJ, HirschauerJ. Head injury in the infant and toddler. Child's Brain. 1984;11:12Reference : Raimondi AJ, HirschauerJ. Head injury in the infant and toddler. Child's Brain. 1984;11:12--35.35.

Ocular responseOcular response

Verbal responseVerbal response

Motor responseMotor response

PursuitPursuit

EOM intact, reactive pupilsEOM intact, reactive pupils

Fixed pupils or EOM impairedFixed pupils or EOM impaired

Fixed pupils or EOM paralyzedFixed pupils or EOM paralyzed

CriesCries

Spontaneous respirationSpontaneous respiration

ApneicApneic

Flexes & extendsFlexes & extends

Withdraws from painful stimuliWithdraws from painful stimuliHypertonicHypertonic

FlaccidFlaccid

44

33

22

11

33

22

11

44

3322

11


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1.1. Reduced cerebral perfusion pressure (CPPReduced cerebral perfusion pressure (CPP == MAPMAP -- ICP)ICP)

2.2. Brain herniation :Brain herniation :

uncal herniation;uncal herniation;

diencephalic and midbrain/upper pontine herniation;diencephalic and midbrain/upper pontine herniation; temporal lobes herniationtemporal lobes herniation

lower pontine and medullary herniationlower pontine and medullary herniation

Note :Note :

Central or uncal herniation through the tentorium isCentral or uncal herniation through the tentorium is

compatiblecompatiblewith intact survival;with intact survival;

Foramen magnum hernation is not compatible with intactForamen magnum hernation is not compatible with intact

survival.survival.

Intracranial HypertensionIntracranial Hypertension


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ICPm

onitoringICP

moni

toring

VentriculostomyVentriculostomy

FiberopticFiberoptic--Tipped Intraparenchymal CatheterTipped Intraparenchymal Catheter

Subdural boltSubdural bolt Subdural/Epidural CatheterSubdural/Epidural Catheter

ElectroencephalographyElectroencephalography

SensorySensory--Evoked PotensialsEvoked Potensials

CPPCPP == MAPMAP -- ICPICP


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Conscious levelConscious level

Brain stem reflexesBrain stem reflexes

Progressive herniationProgressive herniation


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Respiratory patternRespiratory pattern PosturePosture

Response to painResponse to pain Pupil size and response to lightPupil size and response to light

Oculocephalic (doll's eye) reflexesOculocephalic (doll's eye) reflexes

Oculovestibular or caloric testingOculovestibular or caloric testing ToneTone

Peripheral reflexesPeripheral reflexes Plantar responsePlantar response

The examination ofthe brain stemThe examination ofthe brain stem


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Note :Note :

Papilloedema is very rarely seen in acutePapilloedema is very rarely seen in acute

encephalopathiesencephalopathies

Corneal, gag, and cough reflexes do not provideCorneal, gag, and cough reflexes do not provide

additional informationadditional information

CT scan is often reported as normalCT scan is often reported as normal


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HistoryHistory

Physical examinationPhysical examination

Funduscopic examinationFunduscopic examination

CT scanCT scan

LumbarLumbar puncturepuncture

Routine haematologyRoutine haematology Thick and thin blood filmsThick and thin blood films

BiochemistryBiochemistry

MicrobiologyMicrobiology

Polymerase chain reaction (PCR)Polymerase chain reaction (PCR) Urine toxicology screenUrine toxicology screen

Magnetic resonanceMagnetic resonance imagingimaging

AngiographyAngiography

VenographyVenography

Diagnosis of comaDiagnosis of coma


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Maintain the airway and the systemicMaintain the airway and the systemic circulationcirculation

Correct metabolic derangementsCorrect metabolic derangements

Shock : plasma, inotropic supportShock : plasma, inotropic support

Correct hypoglycaemiaCorrect hypoglycaemia

Fluid therapy (Note : 5Fluid therapy (Note : 5 or 10% dextrose are contraindicatedor 10% dextrose are contraindicated

Maintained blood pressureMaintained blood pressure

Treated seizuresTreated seizures

Cover the possibility of infectionCover the possibility of infection Immediate ventilation and transfer to PICU/neurosurgeryImmediate ventilation and transfer to PICU/neurosurgery

Emergency managementEmergency management


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Monitoring of ICPMonitoring of ICP

Maintenance of an adequate CPPMaintenance of an adequate CPP Management of persistent Intracranial HypertensioManagement of persistent Intracranial Hypertensio

Monitoring EEG and seizure activityMonitoring EEG and seizure activity

Management principlesManagement principles of comaof coma


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> 6 hours> 6 hours ---- ICP monitoringICP monitoring

Maintain CPP above a minimum of 50Maintain CPP above a minimum of 50 mm Hgmm Hg

Surgical management : mass lesion, acute hydrocephaluSurgical management : mass lesion, acute hydrocephalu

The head in the midline, flat or tilted up to 30The head in the midline, flat or tilted up to 30 Suction with great cautionSuction with great caution

Ventilate to normocapniaVentilate to normocapnia

Fluid managementFluid management

Barbiturate therapy ?Barbiturate therapy ?

Normothermia or mild hypothermiaNormothermia or mild hypothermia

Seizures controlSeizures control

Infection controlInfection control

Manage

ment

unconscious childM

anagem

ent

unconscious child


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COMAALGORYTHM

Hystory

Physical examination

CBC, diff count, platelet, ABG,,

SGOT, Urinalysis, Electrolyte,

BUN, creatinine, glucose.Supportive care

Hospitalize

Assess level of brain dysfunction

Variation ? Consistency ?

Toxic metabolic !! Mass lesion !!

CT/MRI

Normal Abnormal

LP

NormalAbnormalStructural !!Infection !! Metabolic test

Toxicology screen

Metabolic !!

Toxic !!


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PrognosisPrognosis

Prolonged coma after a hypoxicProlonged coma after a hypoxic--ischaemicischaemic ---- poor prognosispoor prognosis

Surviving infectious encephalopathiesSurviving infectious encephalopathies ---- good outcomegood outcome

Cortical blindness often recoversCortical blindness often recovers

Hemiparesis, choreaHemiparesis, chorea improveimprove

Cognitive function may recoverCognitive function may recover

Concentration may be poorConcentration may be poor

Behavioural difficulties are very commonBehavioural difficulties are very common


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The brain function ceased completelyThe brain function ceased completely

Pulmonary and cardiac functions can still bePulmonary and cardiac functions can still be

maintained artificiallymaintained artificiallyDiagnosed clinically in the majority of patientsDiagnosed clinically in the majority of patients

(negative brain stem reflex)(negative brain stem reflex)

EEG : flatEEG : flat

Flow index of transcranial Doppler ultrasound


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Brain Failure