Brain failure

KOMA

Berasal dari kata Yunani = tidur yang

Manifestasi gagal otak paling bera
Penurunan tingkat kesadaran paling

KESADARAN

Awake/arousal (bangun) :
Reticular Activating System (RAS)
MedullaCentral MO--ThalamusCorte
Bentuk kesadaran paling primitif
Awareness (waspada) : Cortex

Tingkat
Kesadaran

Awake

Aware

(+)
(+)
Compos Mentis
</(+)
Obtundasi (apatis) </(+)
Letargik (somnolen)dirangsang (+)
rangsang kuatmenurun
Stupor (sopor)
(+)
(-)
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 (?)

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 Traune
Children's Coma Score (Raimondi and Hirschaue
Adelaide Paediatric Coma Scale (Simpson and R
Seshia scale

Modified Glasgow Coma Scale (James and Trauner,

>5 years
Activity
<5 years
Score
Eye-openingSpontaneous
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 soundsMoans to pain

2

No response to pain
No response to pain
1
Obeys commands
Motor
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 Extension
pain
to supraocular pain
2
No response
No response
1
Score 8 = Comatose

Score 9 = Non Coma

Children's Coma Score

(Raimondi and Hirschauer)

Ocular responsePursuit
4
EOM intact, reactive pupils
3
Fixed pupils or EOM impaired 2
Fixed pupils or EOM paralyzed 1
Verbal responseCries
3
Spontaneous respiration
2
Apneic
1
Motor responseFlexes & extends
4
Withdraws from painful stimuli 3
Hypertonic
2
Flaccid
1

EOM = Extra ocular muscles; Total = (Maximum score assignable is 11, m

Reference : Raimondi AJ, Hirschauer J. Head injury in the infant and toddler. Child's Brain. 1984

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 Cath
Subdural bolt
Subdural/Epidural Catheter
Electroencephalography
Sensory-Evoked Potensials

CPP=MAP-ICP

Progressive herniation
Conscious level
Brain stem reflexes

The examination of the brain ste

st

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 : 5or 10% dextrose are contraind
Maintained blood pressure
Treated seizures
Cover the possibility of infection
Immediate ventilation and transfer to PICU/neurosurg

Management principles of coma

Monitoring of ICP
Maintenance of an adequate CPP
Management of persistent Intracranial Hyper
Monitoring EEG and seizure activity

Management unconscious child

> 6 hours -- ICP monitoring

Maintain CPP above a minimum of 50mm Hg
Surgical management : mass lesion, acute hydroce
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
Physical examination

CBC, diff count, platelet, ABG,,

SGOT, Urinalysis, Electrolyte,
BUN, creatinine, glucose.

Supportive care
Hospitalize
Assess level of brain dysfunction
Variation ?
Toxic metabolic !!

Consistency ?
Mass lesion !!
CT/MRI

LP
Abnormal

Normal

Infection !!

Metabolic test
Toxicology screen
Metabolic !!
Toxic !!

Normal

Abnormal
Structural !!

Prognosis

Prolonged coma after a hypoxic-ischaemic -- poor pro

Surviving infectious encephalopathies -- good outcom
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 < 0.8more than 2 hours :
irreversible brain stem death