Microsoft PowerPoint - coma and brain death 2002

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1 Coma and Brain Death ( 昏迷與腦死 ) Conscious be aware or sensible of an inward state or outward fact ( 周知表裡的 ) Consciousness ( 意識 ) state of being conscious; awareness of the self and the environment ( 自知自覺的狀態 ) Coma ( 昏迷 ) Consciousness disturbance (not conscious disturbance), Comatose (not comatous) 意識狀態與昏迷意識狀態 : 具有區別與認知本身和環境的能力客觀評估 : 外表 : 清醒或睡眠狀態行動 : 自主及隨意性, 對刺激有意義的反應昏迷 : 不能區別與認知本身和環境客觀評估 : 外表 : 睡眠狀行動 : 對刺激不能產生有意義的反應

2 Brainstem RAS (mid-pons rostrally) and its projections to the hemispheres Anatomic basis of coma (results from lesions that affect either the RAS or both hemispheres)

3 意識之成分喚醒度 (Arousal): 意識之能力 1. 臨床現象 : 外表呈醒的狀態 ( 能主動睜眼或對外界刺激有睜眼反應 ) 2. 是腦幹之網狀系統活動的表現 3. 主為腦幹之功能覺察能力 (Awareness): 意識之內容 1. 綜合認知和情感之腦功能 2. 臨床現象 : 有意義的動作和語言 3. 主為大腦半球的功能 Consciousness Disturbance ( 意識障礙 ) Arousal / Level: maintained wakefulness by intact ARAS and both cerebral hemispheres Lethargy, Drowsy, Obtundation, Stupor, and Coma Cognitive content: sum of mental function, leading to awareness of self and environment and the expression of psychological functions of sensation, emotion and thought Confusion, Delirium, Psychosis, Illusion, Hallucination etc.

4 Glasgow Coma Scale (Teasdale & Jennett, 1977) Eye Opening 4-1 Verbal Response 5-1 Motor Response 6-1 Eye Opening Spontaneous 4 To speech 3 To pain 2 None 1

5 Verbal Response Orientated 5 Confused 4 Words 3 Sounds 2 None 1 Motor Response Obeys commands 6 Localizing to pain 5 Withdrawal from pain 4 Flexion to pain 3 Extending to pain 2 None 1

6 昏迷的原因幕 (supratentorial) 病灶.. 20% 幕 (infratentorial) 病灶 13% 瀰漫性或新陳代謝 (diffuse/metabolic) 腦病 65% 心因性 (psychogenic) 之無反應 ( 假昏迷 ). 2% 依據 Plum and Posner (1980): (500 例 ) Causes of Consciousness Disturbance Howard RS (1995): 40% drug ingestion 25% hypoxic-ischemic insult 20% stroke ICH, basilar a. thrombosis 15% general medical disorders

7 Goal of N.E. in Consciousness Disturbance To establish the existence of clinical diagnosis of coma To localize the neurologic lesion To provide clues about underlying cause Neurologic Examination in Consciousness Disturbance Vital sings (TPR) and Skin before N.E. Level of consciousness: GCS Respiratory patterns: Cheyne-Stokes, hyperventilation, apneustic, ataxic Brainstem reflexes: pupils, corneal reflex, reflex eye movements Motor and reflex signs Meningism

8 Abnormal respiratory patterns associated with pathologic lesions at various levels of the brain Major brainstem reflexes used in the coma examination

9 Pupils in comatose patients Brainstem pathways mediating conjugate horizontal eye movements

10 Caloric Test for Vestibular Function ( cc ice water for oculovestibular reflexes in comatose patients) Oculocephalic and Oculovestibular reflexes in comatose patients with: (1) brainstem intact (doll head eye phenomenon) (2) bil. MLF involvement (3) and low brainstem lesion

11 Internuclear Ophthalmoplegia (left MLF lesion) Looking forward Looking to left Looking to right Convergence Motor responses to noxious stimulation in acute cerebral dysfunction. A = Rt hemisphere B = Diencephalon C = Midbrain/Pons D = Medulla

12 Meningeal Signs: Neck stiffness, Brudzinski sign Kernig Sign: Meningism or Lumbar Disc Herniation

Brain stem intact: (-)lateralizing sign & (-)meningism Diffuse, metabolic, toxic encephalopathy (±)lateralizing sign & (+)meningism Meningitis, SAH (+)lateralizing sign & (-) meningism

13 Brain stem intact: (-)lateralizing sign & (-)meningism Diffuse, metabolic, toxic encephalopathy (±)lateralizing sign & (+)meningism Meningitis, SAH (+)lateralizing sign & (-) meningism Supratentorial lesions Brain stem dysfunction: Infratentorial lesion (brainstem or cerebellar) Herniation Lumbar Puncture (CSF Exam): Meningitis or Subarachnoid Hemorrhage (SAH) Probable Causes of Coma by N.E.

14 幕 (supratentorial) 病灶最早出現的症狀通常為大腦局部障礙漸進性之昏迷 ( 因腦幹 ARAS 之進行性功能障礙所致 ) 腦幹功能障礙由而進行 : 間腦腦橋腦延腦運動功能障礙常為兩側不對稱 Supratentorial Mass with Brain Herniation 1. Cingulate (subfalcine) herniation 2. Transtentorial (central) herniation 3. Uncal herniation: uncus edge of tentorium III & cerebral peduncle 4. Tonsillar herniation

15 Uncal Herniation: coma with ipsilateral oculomotor palsy and contralateral hemiplegia Neurologic signs in coma with downward transtentorial herniation

16 幕腔之病灶突發性昏迷, 或昏迷前先呈現腦幹之機能障礙昏迷發生時, 伴隨 ( 或先有 ) 局部性之腦幹徵候 ; 其幾乎㆒定有異常之 Brain Stem Reflexes 通常有顱神經之障礙常常在早期即出現奇異的 (bizarre) 呼吸型態 hyperventilation,apneustic,ataxic 瀰漫性 / 新陳代謝性腦病 (Diffuse/Metabolic Encephalopathy 精神混亂或輕度昏迷為最早出現之症狀常有不隨意運動 :asterixis, myoclonus, tremor, seizures etc. 運動系統症狀通常為兩側對稱性常發生換氣過度 (hyperventilation) 或換氣不足 (hypoventilation) 之現象酸 - 鹼不平衡即使在昏迷狀態, 兩眼瞳孔縮小對光反應正常

17 心因性 (Psychogenic ) 無反應 ( 假昏迷 ) 呼吸正常或換氣過度兩眼做故意緊閉, 手捏住病鼻子會張口呼吸兩側瞳孔對光反射呈收縮或擴張現象眼前庭反射正常肌肉張力正常或時緊時鬆病態反射 (Babinski sign) 不會出現 Assessment and Management of Acute Coma 1. Stabilization Airway control Oxygenation and ventilation Adequate circulation (includes avoidance of hypotension in stroke) Cervical stabilization head injury or cervical trauma, RA

18 Assessment and Management of Acute Coma - 2. Coma Cocktail Thiamine 100mg IV Dextrose 50% 50 ml IV (may held if immediate fingerstick glucose available) Naloxone mg IV or Flumazenil (Anexate) mg IV Obtain blood for CBC, PT, PTT, chemistry panel, toxic screen, blood cultures Assessment and Management of Acute Coma - 3. Threatening Conditions Elevated ICP head CT Meningitis, encephalitis LP, blood cultures Myocardial infarction EKG Hypertensive encephalopathy early therapy Status epilepticus EEG Acute stroke consider thrombolytic therapy

19 Outcome from Coma Not possible to assess the prognosis with complete accuracy Coma by drug ingestion good prognosis Traumatic coma > similar level of coma from nontraumatic causes Prognostic factors in nontraumatic coma: etiology, depth & duration of coma Assessment and Management of Consciousness Disturbance Early Therapy for Threatening Conditions To Prevent or Diminish Disability and Mortality

20 腦死 (Brain Death) 死亡 : 呼吸停止心跳停止和瞳孔放大且無反應心肺輔助器及器官移植 1968 Ad Hoc Committee of the Harvard Medical School: brain death 1971, Mohandas & Chou: brainstem death 1976 英國皇家醫學院訂定腦死的標準大腦及腦幹之功能大腦 : 思考記憶認知識別意志行為智力語言格情緒等意識之察覺能力 (awareness) 腦幹 : 大腦與脊髓之間的神經路徑司營自主呼吸心跳及其它器官之神經樞

21 Total Brain Death

Cerebral Death Vegetative State Vegetative State Be awake, eyes opening, but no awareness of self or environment, Unable to interact with others No

22 Cerebral Death Vegetative State Vegetative State Be awake, eyes opening, but no awareness of self or environment, Unable to interact with others No sustained, reproducible, purposeful or voluntary behavioral responses Breathing spontaneously, normal brainstem reflexes Inconsistent nonpurposive movements

23 Persistent Vegetative State (PVS) American Multi-Society Task Force PVS: Vegetative state has continued for at least one month, but not imply permanency or irreversibility Outcome of PVS: age, etiology, duration 12 months after traumatic injury, 3 months after nontraumatic insult PVS be permanent Brainstem Death is Brain Death

24 Brainstem Reflexes for Coma 診斷腦幹死之㆔步驟符合必要的先決條件 : 深度昏迷且沒有自主性呼吸, 昏迷的原因為不能醫治之腦部結構損壞, 而這種損壞會導致死亡排除具有可復原性的昏迷病因 : 低體溫藥物毒代謝或內分泌障礙無自主性呼吸 (>12hrs) 並試驗以確定無腦幹反射

25 腦死為了利用死者的器官進行移植應嚴格規定並遵守診斷腦幹死之步驟及其宣布死亡以免浪費可供移植之器官腦幹死就是腦死及個體的死亡

PowerPoint Presentation

PowerPoint Presentation 昏迷的诊断杜万良北京天坛医院神经内科 2007.11.1 1 意识 ( consciousness) 觉醒水平 - 上行网状激活系统意识内容 - 皮层 2 上行网状激活系统 The ascending reticular activating system (ARAS) 3 意识障碍 ( disturbance of