HÔN MÊ (COMA) BÀI GIẢNG CHO BSNT VINUNI

Mô tả cơ chế hôn mê hoặc suy giảm ý thức Tiếp cận bệnh nhân hôn mê Thực hiện chiến lược tiếp cận nguyên nhân hôn mê Khám và xử trí bệnh nhân hôn mê Thảo luận về tiêu chuẩn chăm sóc điều trị hôn mê

APPROACH TO COMA

Dr Phuong Nguyen

• To describe the mechanism for coma or impaired consciousness

• To recognize the major stroke syndromes

• To implement a strategy in approaching case discussions of stroke

• To discuss the standard of care treatment and prevention of stroke

DEFINITION?

KHÁI NIỆM

1 Coma is state of complete behavioural unresponsiveness to external stimulation

2 ScienceDirect: Coma is defined as the absence of any cerebrally

mediated response to noxious stimuli, including pain in all extremities

3 Uptodate: Stupor and coma are clinical states in which patients have

impaired responsiveness (or are unresponsive) to external stimulation and are either difficult to arouse or are unarousable Coma is defined as

"unarousable unresponsiveness" An alert patient has a normal state of

arousal The terms "stupor," "lethargy," and "obtundation" refer to states

between alertness and coma These imprecise descriptors should generally not be used in clinical situations without further qualification

4 Mayoclinic: Coma is a state of prolonged loss of consciousness

KHÁI NIỆM

1 Tình trạng BN mất hoàn toàn chức năng thức tỉnh, đáp ứng và chức năng

nhận thức, bên cạnh đó còn có những rối loạn tim mạch hô hấp và thực vật kèm theo

Các trạng thái lú lẫn, ngủ gà và u ám kể trên đ ược gọi chung là giai đoạn tiền hôn mê (PGS.TS Nguyễn Văn Chương _ Thần kinh học)

2 The Washington Manual of critical Care (Michael Rubin)

 PATHOPHYSIOLOGY?

Three Stroke Types

illustration of the various stages of a coma, from right to left : normal state, minimally conscious, vegetative state, deep coma, irreversible coma (or brain dead) the x and y axes correspond to the cognitive and motor capacities capacity diminishes the more the patient heads towards an irreversible coma

ascending reticuler activaiting system- ARAS

 PATHOPHYSIOLOGY

MỨC ĐỘ HÔN MÊ

HOW DO YOU APPROACH TO THE COMATOSE PATIENT?

BẤT ĐỘNG CSC

• NẸP CSC

• Xquang hoặc CT csc

• Khám chuyên khoa PT TK

ĐIỀU TRỊ KHẨN CẤP NGAY

• BN hôn mê cấp tính CRNN, phải được dung:

- Thiamin 100mg TM

- Glucose 50%, tiêm TM ngay sau khi tiêm Thiamin

- Naloxon 0,4-2mg tiêm TM: Có tác dụng trung hòa nhanh các chế phẩn opioid, có thể làm cho BN tỉnh, hoặc sảng (HC cai)

NGUYÊN NHÂN HÔN MÊ

EXAMINATION OF COMATOSE

Level of Arousal

HÌNH THỂ BN

PHẢN XẠ THÂN NÃO

https://www.slideshare.net/AbdullahAnsaari/approach-to-the-comatose-patient-120231779

https://www.slideshare.net/thinhtranngoc98/chn-on-v-x-tr-cp-cu-bnh-nhn-hn-m

Case Discussions

NEXT STEPS

What would be the etiology of this stroke?

Which diagnostic tests would you order?

What would be your next step in management?

What treatments/prevention strategies would you suggest for this patient?

MANAGEMENT OF ISCHEMIC STROKE

Harrison’s Principle of Internal Medicine 20 th edition chapter 420: Ischemic Stroke

- Rapid reversal of ischemia is the most important

aspect in salvaging ischemic brain tissue that is not

already infarcted (The Penumbra!)

- You want to know whether the patient is eligible for

intravenous thrombolysis and/or mechanical

thrombectomy – ALWAYS ASK FOR THE LAST TIME

THE PATIENT WAS NORMAL!

What is a Penumbra?

- The ischemic penumbra is an area of dysfunctional

tissue surrounding the core area of infarction that can

be salvaged since it is ischemic but has not infarcted

- This area will eventually progress to infarction (dead

tissue) if no change in flow occurs

- Saving the penumbra is the goal of revascularization

therapies

CT Perfusion study show hypoperfusion of the right hemisphere

MANAGEMENT CONTINUED – IV TPA & THROMBECTOMY

Jamary Oliveira Filho, Owen B Samuels Approach to reperfusion therapy for acute ischemic stroke, updated April 8, 2020 In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA (Accessed on April 27, 2020)

- Intravenous alteplase (recombinant tissue

plasminogen activator or tPA) is a clot busting

drug that is used to break up the clot responsible

for an ischemic stroke

- Window: can be given in 3 - 4.5 hours from

stroke onset if there are no contraindications

- Long list of contraindications including: CT

showing a hemorrhage, time last seen normal >

4.5 hours, platelet count < 100,000, recent GI

bleeding, sustained BP >185/110 mmHg despite

treatment, major surgery in preceding 14 days

neurosurgery or head trauma in last 3 months,

glucose < 50 or > 400

- Post receiving TPA, patient should go to neuro

ICU for close monitoring

Intra-arterial mechanical thrombectomy:

- Uses a stent retriever device to manually remove the clot

- Used in patients with ischemic stroke caused by a large artery occlusion in the proximal anterior circulation

- Can be performed up to 24 hours

after symptom onset in certain patients

- Can be done in patients who got IV TPA

KEY TAKE HOME POINTS

- Stroke is divided into two major categories: Ischemic and

Hemorrhagic

- The three main etiologies of an ischemic stroke are thrombotic, embolic, and hypoperfusion

- The two main types of hemorrhagic strokes are intracerebral

hemorrhage and subarachnoid hemorrhage

- Know the main stroke syndromes – MCA/ACA/PCA artery

strokes

- NIH Stroke scale is used to evaluate the acuity of stroke

KEY TAKE HOME POINTS CONTINUED

- When a patient presents with focal neurological deficits, always make

sure that vital signs are stable and find out the time patient was last

known to be normal

- Get a stat CT head to make sure there is no evidence of bleeding

- Remember, Time is Brain Saving the penumbra is the key to saving

brain tissue that would otherwise be dead

- Consult neurology for consideration of TPA (if <4.5 hours) or mechanical thrombectomy (upto 24 hours)

- Assess the etiology of the stroke to guide what treatments to follow

- If there is a concern for hemorrhagic stroke, consult neurosurgery and make sure to keep a tight control on blood pressure

REFERENCES / ADDITIONAL READING

2) Stroke (2020, March 4). Physiopedia,  Retrieved 23:21, April 25, 2020 from https://www.physio-pedia.com/index.php?

nations." Neurosurgical focus 45.4 (2018): E12.

6) Brott, Thomas, et al "Measurements of acute cerebral infarction: a clinical examination scale." Stroke 20.7 (1989):

864-870.

7) Jamary Oliveira Filho, Owen B Samuels Approach to reperfusion therapy for acute ischemic stroke, updated April 8,

2020 In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA (Accessed on April 27, 2020)

8) Kernan, Walter N., et al "Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a

guideline for healthcare professionals from the American Heart Association/American Stroke Association." Stroke 45.7

(2014): 2160-2236.

9) Hemphill, J Claude, et al "The ICH score." Stroke 32.4 (2001): 891-7.

10) Morgenstern, Lewis B., et al "Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for

healthcare professionals from the American Heart Association/American Stroke Association." Stroke 41.9 (2010):

2108-2129.