Brain failure

KOMA

 Berasal dari kata Yunani = tidur yang dalam

 Manifestasi “gagal otak” paling berat
 Penurunan tingkat kesadaran paling rendah
 KESADARAN

 Awake/arousal (bangun) :
Reticular Activating System (RAS)
Medulla—Central MO--Thalamus—Cortex
Bentuk kesadaran paling primitif
 Awareness (waspada) : Cortex
Tingkat
Kesadaran Awake Aware

Compos Mentis (+) (+)

Obtundasi (apatis) </(+) </(+)
Letargik (somnolen) dirangsang (+)
Stupor (sopor) rangsang kuat menurun
Vegetatif (+) (-)
Koma (-) (-)

Coma = neither awake nor aware

 Etiology
Structural
Trauma, Intracranial haemorrhage, Brain abscess, Neoplasms
Cerebro-vascular accident, Cerebral venous sinus thrombosis,
Infarct
Metabolic (encephalopathy)
Infection, Meningitis, Encephalitis, Cerebral Malaria,
Poisoning, Hypoxia, Hypercarbia, Metabolic acidosis,
Hyponatremia, Hypoglycemia, Congestive heart failure, Shock,
Cyanotic spell, Diabetic ketoacidosis, Insulin dependent
diabetes mellitus, Hypopituitarism, Hypothyroidism, Renal
failure, Liver failure, Hypothermia, Heat stroke, Epilepsy,
convulsion, Inborn-errors of metabolism
Psychiatric (?)
Histeria, Catatonia
Unconscious ?
How deeply ?
ICP raised ?
Emergency management ?
Management of unconscious child ?
Prognosis?
 Scoring system

 Glasgow Coma Scale (Teasdale and Jennet)

 Modified Glasgow Coma Scale (James and Trauner)
 Children's Coma Score (Raimondi and Hirschauer)
 Adelaide Paediatric Coma Scale (Simpson and Reilly)
 Seshia scale
 Modified Glasgow Coma Scale (James and Trauner, 1985)
Activity >5 years <5 years Score
Eye-opening Spontaneous Spontaneous 4
  To voice To voice 3
  To pain To pain 2
  None None 1
Verbal Orientated Alert, babbles, coos 5
Confused Irritable 4
  Inappropriate words Cries to pain 3
  Incomprehensible sounds Moans to pain 2
  No response to pain No response to pain 1
Motor Obeys commands Spontaneous movements 6
Localises to supraocular pain Localises to supraocular pain) 5
Withdraws nailbed pressure Withdraws nailbed pressure 4
Flexion to supraocular pain Flexion to supraocular pain 3
Extension to supraocular pain Extension to supraocular pain 2
No response No response 1
Score ≤ 8 = Comatose Score  9 = Non Comatose
 Children's Coma Score
(Raimondi and Hirschauer)
Ocular response Pursuit 4
EOM intact, reactive pupils 3
Fixed pupils or EOM impaired 2
Fixed pupils or EOM paralyzed 1
Verbal response Cries 3
Spontaneous respiration 2
Apneic 1
Motor response Flexes & extends 4
Withdraws from painful stimuli 3
Hypertonic 2
Flaccid 1
EOM = Extra ocular muscles; Total = (Maximum score assignable is 11, minimal 3)
Reference : Raimondi AJ, Hirschauer J. Head injury in the infant and toddler. Child's Brain. 1984;11:12-35.
 Intracranial Hypertension

1. Reduced cerebral perfusion pressure (CPP = MAP - ICP)

2. Brain herniation :
 uncal herniation;
 diencephalic and midbrain/upper pontine herniation;
 temporal lobes herniation
 lower pontine and medullary herniation
Note :
Central or uncal herniation through the tentorium is compatible
with intact survival;
Foramen magnum hernation is not compatible with intact survival.
 ICP monitoring
 Ventriculostomy
 Fiberoptic-Tipped Intraparenchymal Catheter
 Subdural bolt
 Subdural/Epidural Catheter
 Electroencephalography
 Sensory-Evoked Potensials

CPP = MAP - ICP
Progressive herniation
 Conscious level
 Brain stem reflexes
 The examination of the brain stem

 Respiratory pattern
 Posture
 Response to pain
 Pupil size and response to light
 Oculocephalic (doll's eye) reflexes
 Oculovestibular or caloric testing Tone
 Peripheral reflexes
 Plantar response
Note :
Papilloedema is very rarely seen in acute
encephalopathies
Corneal, gag, and cough reflexes do not provide
additional information
CT scan is often reported as normal
 Diagnosis of coma
 History
 Physical examination
 Funduscopic examination
 CT scan
 Lumbar puncture
 Routine haematology
 Thick and thin blood films
 Biochemistry
 Microbiology
 Polymerase chain reaction (PCR)
 Urine toxicology screen
 Magnetic resonance imaging
 Angiography
 Venography
 Emergency management

 Maintain the airway and the systemic circulation

 Correct metabolic derangements
 Shock : plasma, inotropic support
 Correct hypoglycaemia
 Fluid therapy (Note : 5 or 10% dextrose are contraindicated)
 Maintained blood pressure
 Treated seizures
 Cover the possibility of infection
 Immediate ventilation and transfer to PICU/neurosurgery
 Management principles of coma

 Monitoring of ICP
 Maintenance of an adequate CPP
 Management of persistent Intracranial Hypertension
 Monitoring EEG and seizure activity
 Management unconscious child

 > 6 hours -- ICP monitoring

 Maintain CPP above a minimum of 50 mm Hg
 Surgical management : mass lesion, acute hydrocephalus
 The head in the midline, flat or tilted up to 30°
 Suction with great caution
 Ventilate to normocapnia
 Fluid management
 Barbiturate therapy ?
 Normothermia or mild hypothermia
 Seizures control
 Infection control
 COMA ALGORYTHM
Hystory CBC, diff count, platelet, ABG,,
Physical examination SGOT, Urinalysis, Electrolyte,
BUN, creatinine, glucose.
Supportive care
Hospitalize

Assess level of brain dysfunction

Variation ? Consistency ?
Toxic metabolic !! Mass lesion !!
LP CT/MRI

Abnormal Normal Normal Abnormal

Infection !! Metabolic test Structural !!
Toxicology screen

Metabolic !!
Toxic !!
 Prognosis

 Prolonged coma after a hypoxic-ischaemic -- poor prognosis

 Surviving infectious encephalopathies -- good outcome
 Cortical blindness often recovers
 Hemiparesis, chorea – improve
 Cognitive function may recover
 Concentration may be poor
 Behavioural difficulties are very common
 Brain death

The brain function ceased completely

Pulmonary and cardiac functions can still be
maintained artificially
Diagnosed clinically in the majority of patients
(negative brain stem reflex)
EEG : flat
Flow index of transcranial Doppler ultrasound <
0.8 more than 2 hours : irreversible brain stem death