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coma Zhang Yinglan MD, Associate chief physician Emergency Department Longhua Hospital Affiliated Shanghai University of TCM Definition the most serious disturbance of consciousness no response to the various external stimuli and cannot be awakened aimless spontaneous activities A clear consciousness an awareness of oneself and surroundings a quick and accurate response to the pain、 touch、seeing、hearing and language The important structure to maintain consciousness reticular activating system in the middle-upper part of the pons the lesion of the lower part of the pons or medulla will not lead to unawareness a complete cerebral cortex Lesion area focal brainstem lesions or bilateral hemisphere with diffuse lesion rapidly progressive lesion in one hemisphere cause the midline shift、 extruding the ascending reticular activating system of the brainstem focal lesions of one hemisphere will not lead to unconsciousness excessive lesions of bilateral hemisphere but slow progress will not lead to unconsciousness(like Alzheimer‘s Disease) mechanism reflex arc General receptor Specific receptor Specific ascending projection system Nonspecific ascending reticular activiting system muscle 、 skeleton Bilateral cerebral cortex Pyramidal tracts Pathogenesis Intracephalic diseases:the primary lesion of cerebral cortex、 interbrain 、 midbrain and the head-end of the pons Systemic diseases(secondary brain injury): poisoning、 infection、 metabolic or endocrine disorders How systemic diseases cause the coma? Obstruction of supply or utilization of oxygen and the substrate The change of neuronal excitability The change of cranial capacity craniocerebral trauma is the most common reason to cause coma internal medicine diseases • cerebrovascular disease 50% • hypoxic-ischemic encephalopathy 20% • the rest are metabolic disease toxic encephalopathy The judgement of coma disturbance of consciousness include degree of awakening declined conscious content changed confusion、 delirium The severity of coma light coma Moderate coma deep coma brain death Confusion:loss of concentration、 disorientation、 indifference、 inconsistent language Delirium:it is an acute advanced nervous disorder and can be seen in hyperpyrexia、 poisoning or metabolic disorders. Special type vegetative state VS:in the vegetative state patients can open their eyelids occasionally and demonstrate sleep-wake cycles, but completely lack cognitive function. minimally conscious state MCS:it is defined as a condition of severely altered consciousness in which minimal but definite behavioral evidence of self or environmental awareness is demonstrated. Diagnostic criteria of VS loss of cognitive function, unconscious activities, disable instruction unable to understand or express language demonstrate sleep-wake cycles open the eyes automatically or with stimulus aimless eyes tracking movement spontaneous breath or blood pressure functions of the hypothalamus and brainstem are basically preserved Classification of VS Persistent vegetative state(PVS)>1 month Permanent vegetative state • brain traumatic>1 year • non-traumatic>3 months transient vegetative state<1 month Special type Decorticate syndrome: extensive lesions in bilateral cerebral cortex Akinetic mutism: damage of brain specific or nonspecific activating system but a complete cortex and efferent pathway Brain death in 1968 Harvard Medical School published the first criteria of brain death in 1981 the United States passed the uniform standards of brain death diagnosis in 2003 Ministry of Public Health of China worked out a criteria of brain death Diagnostic criteria of brain death Brain death is the complete and irreversible loss of brain function (including involuntary activity necessary to sustain life) Clinical criteria • deep coma • brainstem reflexes disappeared • no spontaneous breathing Comfirmation test • electrical silence of ECG • non-perfusion of transcranial color doppler (TCD) • short latency somatosensory evoked potentials(SLSEP) disappeared Glasgow Coma Scale The Glasgow Coma Scale provides a score in the range 3-15; patients with scores of 38 are usually said to be in a coma. 3’ → poor prognosis 15’ → better prognosis Differential diagnosis hysterical lethargy syncope affective stupor shock narcolepsy locked-in syndrome Diagnostic program medical history physical examination observation assistant examination and vital signs Key points of inquiry initial symptoms,the speed of onset? medication history, drinking history and toxic exposure? brain trauma history? HBP、DM or a history of heart、lung、 brain、liver、kidney? fever ? How to estimate extracephalic or intracephalic disease intracephalic disease systemic disease initial symptoms headache,convulsion, mental disorder, paralysis primary disease's perform ance intracranial hypertention obvious not obvious location sign of central nervous system yes no radiography abnormal normal cerebral spinal fluid maybe abnormal normal intracranial disease types of onset acute angiopathy trauma infection subacute chronic infection tumor subdural or epidural hematoma location sign focal signs angiopathy trauma tumor meningeal irritation subarachnoid hemorrhage meningitis sinus thrombosis Localization diagnosis from special type of breath type of breath diseased region apnea after overventilation bilateral frontal lobe Cheyne-Stokes breathing hemisphere conditioned central neurogenic hyperpnea midbrain apneusis upper part of the pons cluster breathing lower part of the pons irregular breathing medulla oblongata Odors in the breath ammonia smell → uremia apple smell → diabetic ketoacidosis garlic smell → organophosphorus pesticide poisoning fetor hepaticus → hepatic encephalopathy alcohol smell→ alcoholism Involuntary movement muscle twitch: uremia、 pulmonary encephalopathy : hepatic encephalopathy 、 pulmonary encephalopathy paroxysmal twitch: carbon monoxide intoxication、 atropine intoxication or some drug poisoning epilepsy : hypertensive encephalopathy、 cerebral hemorrhage、 craniocerebral injury choreic movement: rheumatic encephalopathy asterixis Brainstem reflexes reflexes location ciliospinal reflex interbrain frontalis-obicular muscle reflex midbrain-interbrain oculocephalogyric reflex pupil light reflex midbrain corneal reflex 、 jaw reflex upper part of pons horizontal oculovestibular reflex lower part of pons oculocardiac reflex medulla corneomandibular reflex inerbrain or midbrain Systemic disease toxic disease metabolic disease:five visceral organ, five pathogenic factors endocrine disease:five glands infectious diseases Toxic disease characteristics • acute onset, toxic exposure • group onset • frequently nausea、vomiting、 diarrhea、 excessive sweating、 convulsion • multiple system damaged • special clinical signs:change in skin color、 body odour、temperature、pupils clinical manifestations • carbon monoxide intoxication → cherry-red lips organophosphorus pesticide poisoning → breath that smells of garlic • sedative intoxication → low temperature 、low blood pressure • contracted pupil → organophosphorus pesticide 、sedative • dilated pupil → atropine poisoning • Five visceral organs cardiogenic coma :severe heart failure、arrhythmia 、 cardiac shock pulmonary coma :chronic bronchitis 、 emphysema 、 pulmonary heart disease hepatic coma :jaundice 、 cirrhosis、 hepatic dysfunction renal coma :oliguria 、 anuria 、anemia、HBP、renal dysfunction brain-derived coma :no systemic disease、 focal signs of CNS Five glands pituitary crisis: severe bleeding after birth、 postpartumamenorrhea or agalactia hypothyroidism crisis: myxoedema、obvious low temperature Addison disease: mucosa pigmentation of the skin、fatigue、 hyponatremia hyperparathyroidism or hypoparathyroidism crisis: significantly increased or decreased of serum calcium pancreatic encephalopathy:abdominal pain、 blood amylase ↑、urine amylase↑ Five pathogenic factors glucose: hypoglycemia or hyperglycemia coma saline:hyponatremia、 hypernatremia acid:metabolic acidosis、 respiratory acidosis toxin:exogenous intoxication blood pressure:hypertensive encephalopathy、 hypotension and shock Conclusion of diagnostic thinking differentiate intracranial diseases 、 systemic disease ( initial symptom 、 intracranial hypertension 、 focal signs ) intracranial diseases : type of onset (acute、subacute、 chronic) location sign ( focal lesion 、 meningeal irritation sign ) systemic disease: toxication metabolism :five visceral organs 、five pathogenic factors endocrine disease :five glands infection