Coma & Brain stem death

Rifdy Mohideen
 What is coma?
Coma is a state of unarousable unresponsiveness

•No evidence of arousal

– no spontaneous eye opening
– no comprehensible speech
– no voluntary limb movement
– No response to external stimuli & surrounding environment

•There may be
– abnormal postures adopted
– eyes may open, or grunts may be elicited in response to pain
– involuntary movements, e.g. seizures or myoclonic jerks, may
occur.
 Coma differs from
• Sleep (arousable)
• Syncope (brief)
• Stupor (aroused with repeated stimuli)

Coma should be differentiated from

• Locked-in syndrome: actually conscious but unable to speak or move,
may move eyes (massive brainstem damage)

• Vegetative state: patients appear to be awake but show no sign of

awareness of themselves or their environment (brainstem intact but
widespread cortical damage); may breath spontaneously
 What is consciousness?

Consciousness is a state of awareness of self and the

environment

This state is determined by two separate functions:

– awareness (content of consciousness)
– arousal (level of consciousness )
Coma is caused by disordered arousal rather than
impairment of the content of consciousness

Arousal is dependent on an intact reticular

activating system located in the brainstem and its
ascending connections
 Is there a way of objectively measuring
consciousness?
• GCS is a useful way of assessing and monitoring level
of consciousness

• This analyses three markers of consciousness

– eye opening
– motor
– verbal responses
 Glasgow Coma Scale
Eye Opening Score
Spontaneous 4
Brain injury classification
To voice 3
To painful stimuli 2 3 coma or death
None 1 =<8 severe
Motor 9-12 moderate
Obeys commands 6 >= 13 minor
Localises pain 5
Withdraws to painful stimuli 4
Flexion to painful stimuli 3 Individual responses and total
scores important
Extension to painful stimuli 2
Makes no movement 1 Reported as E3 M3 V4
Verbal Tracheal intubation and severe
Oriented 5 eye/facial injury may invalidate
Confused
verbal response
4
Inappropriate words 3
Unintelligible sounds 2
Makes no sound 1
 Mechanisms of coma

• diffuse or extensive processes affecting the

whole brain (toxins, metabolic, ischaemic,
infections)

• supratentorial mass lesions causing tentorial

herniation with brain stem compression

• infratentorial mass lesions and vascular

lesions
 Management of coma

• detect and treat any immediately life-threatening

condition

• determine the site and cause of the lesion

– history (eyewitness, family, friends)
– examination (general and neurological; motor
responses to stimuli, respiratory patterns, pupils, and
eye movements)
– investigations (focused)
 Brain death

• vital functions can now be maintained artificially for

a long period of time after the brain has ceased to
function but is futile
• need to diagnose brain death with utmost accuracy
and urgency
• brain dead is legally and clinically dead
• ethical reasons
• retrieval of organs
 Brain death - definition

• an irreversible loss of all functions of the brain,

including the brainstem
• three essential findings
– coma
– absence of brainstem reflexes
– apnoea (no spontaneous respiration)
 Brain death - pathology

• swelling of brain and brainstem

• tentorial and foraminal herniation
• absence of blood flow
• 10% of brain and 60% of spinal cord may appear
normal
 Diagnosis of brain death

• The diagnosis of brain death is primarily clinical

• No other tests are required if the full clinical

examination, including each of two assessments of
brain stem reflexes and a single apnoea test, are
conclusively performed
 Determination of brain death
• history or physical examination findings
• exclusion of conditions that might confound the subsequent examination
of cortical or brain stem function
• performance of a complete neurological examination including the
standard apnea test and 10 minute apnea test
• assessment of brainstem reflexes
• clinical observations compatible with the diagnosis of brain death
• responsibilities of physicians
• notify next of kin
• interval observation period
• repeat clinical assessment of brain stem reflexes
• confirmatory testing as indicated
• certification and brain death documentation
History & physical examination of brain
dysfunction
identification of the proximate cause and irreversibility of coma
severe head injury
massive intracerebral bleed
aneurysmal subarachnoid hemorrhage, hypoxic-ischemic brain insults
fulminant hepatic failure

Exclude
Shock/ hypotension
Hypothermia - temperature < 32°C
Drugs known to alter neurologic, neuromuscular function and
electroencephalographic testing
Medical conditions (e.g. brain stem encephalitis)
 Complete neurological examination
• Absence of spontaneous movement, decerebrate or decorticate
posturing, seizures, shivering, response to verbal stimuli, and response to
noxious stimuli administered through a cranial nerve path way

• Absent pupillary reflex to direct and consensual light

• Absent corneal, oculocephalic, cough and gag reflexes

• Absent oculovestibular reflex

• Failure of the heart rate to increase by more than 5 beats per minute after
1- 2 mg. of atropine intravenously

• Absent respiratory efforts in the presence of hypercarbia when ventilator

is switched off and PaCo2 rises above 6.7kPa (50mmHg) (apnoea test is
performed after the second examination of brainstem reflexes)
 Assessment of brainstem reflexes
• Pupils- no response to bright light (absent light reflex - cranial nerve II and
III)
• Ocular movement- cranial nerve VIII, III and VI
– No oculocephalic reflex (testing only when no fracture or instability of
the cervical spine or skull base is apparent)
– No deviation of the eyes to irrigation in each ear with 50 ml of cold
water (tympanic membranes intact; allow 1 minute after injection and at
least 5 minutes between testing on each side)
• Facial sensation and facial motor response
– No corneal reflex (cranial nerve V and VII)
– No jaw reflex (cranial nerve IX)
– No grimacing to deep pressure on nail bed, supraorbital ridge, or
temporo-mandibular joint (afferent V and efferent VII)
• Pharyngeal and tracheal reflexes (cranial nerve IX and X)
– No response after stimulation of the posterior pharynx
– No cough response to tracheobronchial suctioning
Clinical observations compatible with the
diagnosis of brain death
• spontaneous movements of limbs other than pathologic
flexion or extension response
• respiratory-like movements (shoulder elevation and
adduction, back arching, intercostal expansion without
significant tidal volumes)
• sweating, flushing, tachycardia
• normal blood pressure without pharmacologic support or
sudden increases in blood pressure
• absence of diabetes insipidus
• deep tendon reflexes; superficial abdominal reflexes; triple
flexion response
• absent plantar reflex
 Determination of brain death contd.
• notify next of kin
– Consent not needed for diagnosis
– Consent needed for removal of life support and organ donation
• interval observation period
– 6 hour observation period
• repeat clinical assessment of brain stem reflexes
– Repeated in full and documented
• confirmatory testing as indicated but is not routine
• 2 physicians required for certification (organ donation)
 Medical Record Documentation
• etiology and irreversibility of coma / unresponsiveness
• absence of motor response to pain
• absence of brainstem reflexes during two separate
examinations separated by at least 6 hours
• absence of respiration with pCO2 ≥ 60 mm hg
• justification for, and result of, confirmatory tests if
used
 Malaysian guidelines

• 1993 - Consensus statement on brain death

• 2003 – Review of above statement
– (Malaysian Society of Neurosciences)

www.neuro.org.my/index.php?sc=allclinicalpractice