MANAGEMENT MANAGEMENT OF COMAOF COMA

By By Dr. G.SrinivasDr. G.Srinivas

Associate Professor of Associate Professor of MedicineMedicine

INVESTIGATIONS INVESTIGATIONS

GUIDED BY HISTORY AND GUIDED BY HISTORY AND EXAMINATIONEXAMINATION

PTS WITH RAISED ICT – LP PTS WITH RAISED ICT – LP CT SCAN CT SCAN MRI MRI

KNOWN CASE OF EPILEPSYKNOWN CASE OF EPILEPSY 1. LEVELS OF 1. LEVELS OF

ANTICONVULSANTS.ANTICONVULSANTS. 2. EEG2. EEG

URINE ANALYSIS FOR GLUCOSE, URINE ANALYSIS FOR GLUCOSE, KETONEBODIES, KETONEBODIES, PROTEIN PROTEIN

PS FOR LEUCOCYTOSIS, MPPS FOR LEUCOCYTOSIS, MP

BLOOD FOR RBS,UREA,AMMONIABLOOD FOR RBS,UREA,AMMONIA

SERUM CREATININE,ELECTROLYTESSERUM CREATININE,ELECTROLYTES

SERUM CALCIUMSERUM CALCIUM

SGOTSGOT

SUSPECTED POISONINGSSUSPECTED POISONINGS

11. ASPIRATION AND ANALYSIS OF . ASPIRATION AND ANALYSIS OF GASTRICCONTENTSGASTRICCONTENTS

2. CHROMATOGRAPHIC ANALYSIS 2. CHROMATOGRAPHIC ANALYSIS OF BLOOD & URINEOF BLOOD & URINE

MANAGEMENTMANAGEMENT INTIALLY BY TAKING CARE OF INTIALLY BY TAKING CARE OF

1. AIRWAY1. AIRWAY

2. BREATHING 2. BREATHING

3. CIRCULATION3. CIRCULATION

MONITORING MONITORING HAEMODYNAMIC MONITORINGHAEMODYNAMIC MONITORING

PULMONARY MONITORINGPULMONARY MONITORING

NEUROLOGIC MONITORINGNEUROLOGIC MONITORING

HAEMODYNAMIC HAEMODYNAMIC MONITORINGMONITORING

HEART RATE HEART RATE

BLOOD PRESSUREBLOOD PRESSURE

CVPCVP

PULMONARY CAP.WEDGE PULMONARY CAP.WEDGE PRESSUREPRESSURE

PULMONARY PULMONARY MONITORINGMONITORING

ABGABG

END TIDAL CAPNOGRAPHYEND TIDAL CAPNOGRAPHY

PULSE OXIMETRYPULSE OXIMETRY

NEUROLOGIC NEUROLOGIC MONITORINGMONITORING

EEGEEG EVOKED POTENTIALSEVOKED POTENTIALS INFRARED SPECTROSCOPYINFRARED SPECTROSCOPY BISPECTRAL INDEXBISPECTRAL INDEX INVASIVE NEUROLOGIC INVASIVE NEUROLOGIC

MONITORINGMONITORING JUGULARBULB MONITORINGJUGULARBULB MONITORING

TREATMENTTREATMENT MENINGITIS / ENCEPHALITISMENINGITIS / ENCEPHALITIS 1. DEFINITIVE1. DEFINITIVE 2. SYMPTOMATIC2. SYMPTOMATIC 3. SUPPORTIVE3. SUPPORTIVE

SUBDURAL EFFUSION/EMPYEMA – SUBDURAL EFFUSION/EMPYEMA – DRAINAGE OF PUS DRAINAGE OF PUS

DKA-CORRECT DEHYDRATIONDKA-CORRECT DEHYDRATION INSULIN DRIPINSULIN DRIP MAINTAINENCE FLUIDSMAINTAINENCE FLUIDS

HYPOGLYCEMIA-DEXTROSE HYPOGLYCEMIA-DEXTROSE BOLUS & MAINTAINENCEBOLUS & MAINTAINENCE

HEPATIC COMAHEPATIC COMA

1. LACTULOSE 1. LACTULOSE

2. 10% DEXTROSE WITH MVI2. 10% DEXTROSE WITH MVI

3. SUPPORTIVE3. SUPPORTIVE

POISONINGSPOISONINGS

1. STOMACH WASH1. STOMACH WASH

2. ANTIDOTE2. ANTIDOTE

3. SUPPORTIVE3. SUPPORTIVE

OPIOD POISONING – NALAXONE 0.01mg/kgOPIOD POISONING – NALAXONE 0.01mg/kg

BENZODIAZEPINES – FLUMAZENILBENZODIAZEPINES – FLUMAZENIL

SALICYLATE SALICYLATE – 1. – 1. STOMACHWASH WITH STOMACHWASH WITH CHARCOAL CHARCOAL 2. REHYDRATION2. REHYDRATION

3. INCREASE URINARY PH-3. INCREASE URINARY PH- IV NAHCO3IV NAHCO3

4. SEVERE CASES-DIALYSIS4. SEVERE CASES-DIALYSIS

CEREBRAL MALARIA-QUININE IVCEREBRAL MALARIA-QUININE IV

SUPPORTIVESUPPORTIVE

ENTERIC ENCEPHALOPATHYENTERIC ENCEPHALOPATHY 1. ANTIBIOTICS1. ANTIBIOTICS 2. 2.

DEXAMETHASONEDEXAMETHASONE

DYSELECTROLYTEMIASDYSELECTROLYTEMIAS HYPONATREMIA-REDUCE LOSSHYPONATREMIA-REDUCE LOSS MAINT. DEFICITMAINT. DEFICIT 3% NACL 1-3ml/kg3% NACL 1-3ml/kg HYPERNATREMIA-RESTICT Na INTAKEHYPERNATREMIA-RESTICT Na INTAKE 1/2 NS1/2 NS HYPERKALEMIA-CAL.GLUCONATEHYPERKALEMIA-CAL.GLUCONATE INSULIN DRIPINSULIN DRIP K+BINDING RESINSK+BINDING RESINS

General measuresGeneral measures

Monitoring VitalsMonitoring Vitals Maintaining fluid & electrolyte Maintaining fluid & electrolyte

balancebalance Input & outputInput & output Temp. controlTemp. control Bladder , bowel , back careBladder , bowel , back care Eye careEye care NutritionNutrition

Prognosis Prognosis Depends on Etiology ,Depends on Etiology , Duration &Duration & Depth of ComaDepth of Coma

PrognosisPrognosis Etiology Etiology

Postictal coma – recovery goodPostictal coma – recovery good Anoxic coma – poor outcomeAnoxic coma – poor outcome Infections – mortality 40 %Infections – mortality 40 %

PrognosisPrognosis DurationDuration

Longer the duration poorer the outcomeLonger the duration poorer the outcome

PrognosisPrognosis Depth Depth

Glasgow coma scale 5 or <5Glasgow coma scale 5 or <5 Fixed dilated pupils for > 2 hrsFixed dilated pupils for > 2 hrs Decerebration Decerebration Cardiorespiratory arrest Cardiorespiratory arrest

ass . With poor outcomeass . With poor outcome

THANK UTHANK U