COMA

BRAIN DEATH

Anesthesia and Intensive Care chair nr. 1 “Valeriu Ghereg”

Coordinator of Anesthesia and Intensive Care programs CUSIM
Svetlana Plamadeala, MD, PhD, associate professor
 Aims of the course

• Neurophysiology of coma
• Causes and levels of consciousness disturbances
• Key concepts of neuro-intensive care
• Cerebral edema
• Assessment of unconsciousness patient
• Principles of neuro-intensive care
• State into which coma resolve
• Brain death
 Aim of the course

• Neurophysiology of coma
• Causes and levels of consciousness disturbances
• Key concepts of neuro-intensive care
• Cerebral edema
• Assessment of unconsciousness patient
• Principles of neuro-intensive care
• State into which coma resolve
• Brain death
 Reticular activating system

Wakefulness Sleep state

 Unconsciousness

• Lesions in the
pathways of RAS

• Intrinsic lesion of
RAS
 Aims of the course

• Neurophysiology of coma
• Causes and levels of consciousness disturbances
• Key concepts of neuro-intensive care
• Cerebral edema
• Assessment of unconsciousness patient
• Principles of neuro-intensive care
• State into which coma resolve
• Brain death
 Levels of consciousness disturbance

• Drowsiness (lethargy)

• Stupor

• Coma
 Coma

• State of unresponsiveness

• Lack of alertness
 Causes

Organic Methabolic

• Head trauma • hypoxia

• Cerebral abscess • fluid and electrolyte disorders
• Cerebral tumors • endocrine abnormalities
• Cerebro-vascular diseases • endogenous toxins
 Aims of the course

• Neurophysiology of coma
• Causes and levels of consciousness disturbances
• Key concepts of neuro-intensive care
• Cerebral edema
• Assessment of unconsciousness patient
• Principles of neuro-intensive care
• State into which coma resolve
• Brain death
 Key Concepts

• Monroe-Kellie Doctrine

• CPP=MAP-ICP

• Cerebral Blood Flow

 Monroe-Kellie law

Skull = Brain substance + Blood + CSF

1200-1600 ml 100-150 ml
100-150 ml

• Extracelular fluid <75 ml

Pressure – volume curve
 CPP = MAP - ICP

• MAP = (sBP + 2 dBP)/3

• ICP keep < 20 mmHg

• CPP > 60 mmHg (50-70 mmHg)

 ICP monitoring

• Ventricular catheter

• Epidural monitor

• Parenchymal monitor

• Subarahnoid monitor
 Ventricular catheter

• Invasive method
• Gold standard of ICP
monitoring
• Risk of infection (ventriculitis,
meningoencephalitis)

• With possibility to • Risk of intracranial bleeding

drain SCF as needed
• Risk of seizures
 Cerebral blood flow

• Blood pressure

• PaCO2

• PaO2
 CBF & BP

Skull= Brain+ Blood+ CSF

 CBF & CO2

Skull= Brain+ Blood+ CSF

 SBF & O2

Skull= Brain+ Blood+ CSF

 Aims of the course

• Neurophysiology of coma
• Causes and levels of consciousness disturbances
• Key concepts of neuro-intensive care
• Cerebral edema
• Assessment of unconsciousness patient
• Principles of neuro-intensive care
• State into which coma resolve
• Brain death
 Cerebral edema

increases in brain of water content

• Vazogenic edema

• Cytotoxic edema
 Vazogenic edema

• Blood-brain barrier
incompetence

• Migration of protein-rich
exudate

• White & green matter

 Vazogenic edema

• Cerebral tumors

• Abscess

• Head trauma

• Meningitis

• Cerebral stroke (ischemic, hemorrhagic)

NB. Corticosteroids demonstrate effectiveness

Cytotoxic edema

• Swelling of neurons, glia, and

endothelial cells

• Unimpaired blood-brain barrier

• Energy depletion
Cytotoxic edema

K 140 mmol/l K 4 mmol/l

Na 15 mmol/l Na 143 mmol/l
 Cytotoxic edema

Hypoperfusion - the first cause

NB. Effective – osmotic agents

 Cerebral herniation

• subfalcine herniation

• lateral transtentorial herniation

• central transtentorial herniation

• cerebellar tonsillar herniation

• herniation into the burr hole

 Aims of the course

• Neurophysiology of coma
• Causes and levels of consciousness disturbances
• Key concepts of neuro-intensive care
• Cerebral edema
• Assessment of unconsciousness patient
• Principles of neuro-intensive care
• State into which coma resolve
• Brain death
 Acute depression in level of
consciousness is a critical,
lifethreatening emergency
that requires a complex systemic
aproach
 Coma-patient examination

ABCDE approach:
A –airway
B – breathing
C – circulation
D – disability
E – exposure

Neurologic examination (advanced)

 Assessment of unconsciousness patient

A – Alert patient

V – Response to Voice

P – Response to Pain

U – Unconsciousness
HILTON GARDEN IN GLASGOW SITY
 Glasgow Glasgow Coma Scale
Eye opening
Spontaneous 4
To speech 3
To pain 2
None 1
Verbal response
Orientated 5
Confused conversation 4
Words (inappropriate) 3
Sounds (incomprehensible) 2
None 1
Motor response
Obey commands 6
Localize pain 5
Flexion normal 4
Flexion abnormal 3
Extend 2

None 1
 Anamnestic

Acut onset Subacut onset

• Cerebral-vascular etiology • Systemic illness

• Generalized epileptic activity • Evolving intracranial mass

• Traumatic brain injury • Degenerative infections

• Drug overdose
 Neurological examination

• Breathing pattern

• Pupillary size and reactivity

• Eye position and movement

• Motor function
Breathing pattern
Pupillary size and reactivity
 Pupillary size and reactivity

• unilateral dilated pupil

• inferolateral eye deviation

• ptosis
Eye position and movement

• Oculocephalic reflex

• Oculovestibular reflex
Oculocephalic reflex

Doll’s eye test

Oculovestibular reflex
Motor function
 Paraclinical tests

• CT scan

• MRI

• Lumbar puncture

• EEG

• Evoked potentials
 Aims of the course

• Neurophysiology of coma
• Causes and levels of consciousness disturbances
• Key concepts of neuro-intensive care
• Cerebral edema
• Assessment of unconsciousness patient
• Principles of neuro-intensive care
• State into which coma resolve
• Brain death
Principles of neuro-intensive care

Skull= Brain + Blood + CSF

Control of cerebral metabolism

 Skull= Brain + Blood + CSF

Osmotic therapy

• Manitol

• 3% NaCl
 Skull= Brain + Blood + CSF

• Patient position

• Temperature control

• Control of Blood Pressure

• Sedation/analgezia/ventilation

• Control of (PEEP)
Skull= Brain + Blood + CSF

Drenage of CSF
 Loop diuretic

• Potentiates osmotic effect

• Reduces ICP by means of the flowing effects:

• Increasing of osmotic gradient
• Reducing of CSF production
• Reducing of the cerebral water compartment

Skull= Brain + Blood + CSF

 Control of cerebral metabolism

• Control of seizure activity

• Barbituric coma

• Hipothermia
Uncontrolled ICP
 Aims of the course

• Neurophysiology of coma
• Causes and levels of consciousness disturbances
• Key concepts of neuro-intensive care
• Cerebral edema
• Assessment of unconsciousness patient
• Principles of neuro-intensive care
• State into which coma resolve
• Brain death
 State into which coma resolve

• Vegetative state

• Akinetic mutism

• “Locked in“ syndrome

 Vegetative state

• State of wakefulness

• Undetectable awareness
 Akinetic mutism

A person with akinetic mutism has "sleep-waking cycles but,

when apparently awake, with eyes open, lies mute, immobile
and unresponsive
• Discontinuation of
cortico-nuclear
and cortico-
medulare ways

Ventral
brainstem
damage
 “Locked in“ syndrome

Le scaphandre et le papillion
 Brain death

Brain injury with unreversible

cessation of the brain and brain stem

functions
 Brain death

The medical and legal definitions of death:

brain death & cardiac death

are the same.

 Summary

• Cerebral injury primary/secondary

• Secondary cerebral injuries – preventable

• Skull= Brain + Blood + CSF

• CPP > 60 mmHg