CASES OF COMA

CASES OF COMA

Definitions:
Decreased levels of alertness, eyes closed, there is no any response to pain stimuli, sometimes accompanied by extension or flexion posture at both extremities

Cause
• supratentorial lesions
- Infarction, hemorrhage, tumor, abscess, trauma
• Lesions subtentorial
- Compression lesions (hemorrhage, infarction, aneurysm, tumor abscess cerebellum)
- Destructive lesions (hemorrhage, infarction, migraine, demyelinisasi)
• diffuse lesions or metabolic
• Psychiatry (conversion, depression, catatonic stupor)

Pathophysiology
• Any condition that causes lesions or disorders at ARAS system, thalamus, and cerebral cortex will cause commas.

Clinical Picture
• Patients do not respond eyes, voice, and movement when given strong pain stimuli.
• Sometimes patients have decorticate or decerebrate posture.

Basic Diagnostics
1. Anamnesis = find information:
- Onset
- Course of the disease
- History of disease
- History of treatment or medication that is consumed
- Injury or trauma at this time,
- Seizure-like activity,
- Other accompanying symptoms (such as hot, past medical problems).

2. General Examination:
- Search for signs of trauma (such as Battle's sig or bruising in the 

   mastoid area; leakage of cerebrospinal fluid)
- Evidence of seizures (tongue biting, urinary incontinence)

Examination

Doll's eye:
There is no cervical injury
Normal (+): the opposite of head motion
Caloric testing:
Intact tympanic membrane, the position of 30 degrees
Cold water - eye deviation
pupil:
Midposition - Anisokor
Pin Point - Reactivity pupil down
fixed dilated

Preliminary Therapeutic Coma

Examination	Management
Airway, Breathing, Circulation	Secure the airway If required to do intubation Check the oxygen saturation, give oxygen if needed Measure blood pressure and pulse Attach cardiac monitor
Began doing laboratory tests	Check glucose levels using the finger test Check arterial blood gas Check the electrolytes, complete blood count, calcium, magnesium, ammonia, drug levels, PT, PTT Consider skrening toxin materials

Supportive Therapy

Thiamine 50-100 mg iv Naloxone (Narcan) 1 ampoule iv D50 iv glucose (at least 25 ml)

Anamnesis

Collect the basis of clinical history  If signs and symptoms lead to meningitis (loss of consciousness, heat, meningismus), consider empiric antibiotic therapy and did a lumbar puncture if there are no contraindications  If signs and symptoms lead to herniation (progressive loss of consciousness, decorticate or decerebrate posture, n.III unilateral paralysis), do efforts to reduce intracranial pressure  If there is evidence of complaints lead to seizures, give loading anti-seizure

CT scan	CT scan of the head without contrast Check the cervical vertebrae injury
Lumbar Puncture	Perform a lumbar puncture to rule out subarachnoid hemorrhage or infection (with a record of the results of the CT scan did not reveal any herniation or other cause of coma)
Other	Give specific therapy according to the results of existing metabolic abnormalities, CT scan or lumbar puncture Perform anamnesis further and more complete

LOSS OF CONCIOUSNESS

LOSS OF CONCIOUSNESS

Definitions:
Awareness:
Better awareness of self and environment capable berintraksi with.
Arousal:
Ability to intraksi with the surrounding environment and the full wake conditions.
awareness:
The ability to accept and understand the contents of the stimulus
Increases Arousal:
Very restless and unable to maintain a focus on relevant stimuli.
Decreased Arousal:
Required a strong and constant stimulation that the patient can maintain attention

Anatomy

Arousal

ARAS

Awareness
cerebral hemispheres with projections of:
brainstem - the hypothalamus - thalamus - cerebral hemispheres

3 Important Areas Of Awareness:
• The reticular formation (upper mesensefalon)
• bilateral diencephalon (Thalamus)
• bilateral cerebral hemispheres
When the lesions found in one area in neuroanatomical structures Conciousness above, either focal or diffuse, there will be disturbance of consciousness

Level Of Consciousness -
Glasgow Coma Scale (GCS)

Poin	Eyes	Verbal	Motorik
6	-	-	Following orders
5	-	good orientation	Able to localize the pain
4	Open eyes spontaneously	Can make a sentence, but found disorientasi	Avoidance of pain stimuli
3	Open eyes to the sound stimuli	Could make the words, but do not form sentences	Flexion (decorticate)
2	Open eyes to the pain stimuli	Only the sound (moaning)	Extensions (decerebrate)
1	No response	No response	No response

Delirium (DSM IV)
• Disturbance of consciousness (reduced awareness of the environment), accompanied by a decreased ability to maintain focus or divert attention
• Change in cognition (memory deficit, disorientation, language disturbance) or perceptual disorder
• Disturbance occurs within a short period of time (usually hours to days) and tends to fluctuate during the course of the disease

Somnolence (Obtundation)
• In this condition, the patient has decreased level of alertness mild to moderate and decreased interest in the surrounding environment.
• Often found as one of the stages of sleep.
• Patients still have avoidance reaction to pain stimulus

Stupor
• Decreased levels of alertness.
• It takes a very strong stimulus to be able to wake the patient in this condition

Coma
There are some characteristics in these conditions, among which are:
• decreased level of alertness,
• eyes closed,
• there is no any response to pain stimuli,
• sometimes accompanied by extension or flexion posture at both extremities

Persistent Vegetative State
• These conditions often arise post-coma.
• Patients in a state of arousal but not aware.
• Unable to understand any sensory stimulus, although the eye is open

Differential Diagnosis
• Akinetik mutism
   - Patients in a state of alert. But it can not recognize anything.  
     There were no spontaneous motor activity

• Locked-in syndrome
- Tetraparese with lower cranial nerve paralysis.
- There is no disturbance of consciousness.
- Patients can still communicate using eye movements.
- Caused by the presence of extensive lesions in the pontine area 
   that is not on the ARAS

MENINGITIS TB

MENINGITIS TB

Pathophysiology

• The primary focus elsewhere. 
• In the early stages a small tubercles found in the brain and meninges. 
• Neurological Complications preceded by tubercles and hypersensitivity reactions to TB antigens in the sub arachnoid space à produce thick exudates in basal cysterna and will include cranial nerves and blood vessels in the circulus willis 
• Barriers to the flow of liquor that will cause obstructive hydrocephalus 
• Inhibits the absorption of CSF so that it can also occur comunicating hirocephalus 
• Infarction occurs when going ok:

         a. vasculitis

         b. direct invasion of bacteria in the blood vessels,

         c. compresi blood vessels due to arachnoiditis

Clinical Picture

Symptoms	Sign
Prodromal Anorexia Weight Loss Cougt Night Sweat CNS Headache Meningismus Altered Level of conciousnes	Adenopathy Adventitious Sound on Auscultation of lungs Choroidal tuberkel Fever (highest in the late aftenoon) Nuchal rigidity Papiledema Fokal Neurological Sign Positive tuberkulin test

Diagnosis

Diagnosa

1. Tuberkulin test
2. Chest X-Ray

• hillar adenopathy
• upper lobe nodular infiltrat
• milliary pattern

    3. CT Scan and MRI

• Hydrocephalus
• Basilar meningeal enhancement post contras
• Cerebral infarktion

      4. CSF Examination

• Lymphocytic pleocytosis
• Hypoglycorrhacia
• Acid fast smear and culture

5. eye Examination for choroidal tuberkles
6. Sputum and urine smear and kulture for acid-fast bacilli

LP examination on TB Meningitis
1. increase in initial pressure
2. cells increased between 10-500 tu MN
3. increased protein 100-500 mg / dl
4. decrease in glucose
5. positive cultures in 75% of cases 3-6 weeks
6. decline in chloride
7. tuberkulostearic positive assay
8. bromine ratio of serum / CSF low

Therapy
In adults;
- INH 5 mg / kg / day, max 300 mg / day
- Rifampicyn 10 mg / kg / day, max 600 mg / day
- Pyrazinamide 15-30 mg / kg / day, max 2 g / day
- On this therapy can be given pyridoksine 50 mg / day.
- In the case of resistance can be given ethambutol 15-20 mg / kg / day

In adults with HIV;
- INH 10-15 mg / kg / day
- Rifampicyn 10-15 mg / kg / day
- Ethambutol 25 mg / kg / day or pyrazinamide 20-30 mg / kg / day and streptomycyn, rifabutin, clofazimine
This therapy is continued for at least 6-9 months and at least 6 months or until a negative culture

American Academy Of Pediatric Recommendations;
- INH 10-15 mg / kg / day, max 300mg
- Rifampicyn 10-20 mg / kg / day, max 600mg
- Pyrazinamide 20-40 mg / kg / day, max 2 g
- Streptomicyn 20-40 mg / kg / day
- Over the past 2 months, followed by INH and rifampicyn day once or 2 times a week for 10 months.

Dexamethasone dose 0.3-0.5 mg / kg / day in the early weeks of therapy followed by prednisone 2 mg / kg / day, tappering for 3-4 weeks.
Indications dexamethasone usage;
1. decline in consciousness
2. Papilledema
3. Focal neurological deficits
4. Opening CSF> 300 mmH2O.

Drug	Side Effects
INH Rifampicyn Ethambutol Pyrazinamide Streptomycin	Hepatotoxic Neuropathy perifer Phenitoin toxicity Hepatotoxic Interstitial nephritis Optic Neuropathy Hepatotoxic Arthralgia with hiperuricemia Vestibular toxicity

Prognosis
When patients present with consciousness down, then the 50-70% mortality. Another thing that affects prognosis;
1. age (the highest mortality when very young or very old)
2. malnutrition
3. miliary tuberculosis
4. patients who worsen underlying illnesses such as alcoholism
5. hydrocephalus
6. cerebrovascular complications
7. low glucose concentration
8. increase in protein concentration
9. prognosis in patients with HIV is determined by CD4 cell count
    at the time he was sick