Bilinç Kaybı Olgusuna Acil Yaklaşım ve Ayırıcı Tanılar
Synopsis
Retiküler Aktivasyon Sistemi (RAS), uyanıklığı sağlamaktan sorumludur. RAS, her iki beyin yarısına da aktivasyon gönderir. RAS'nin işlev bozukluğu veya yetersiz aktivasyonu, bilincin bozulmasına neden olur. Doktorlar, bilinç seviyelerini normal durumdan en şiddetli bilinçsizliğe kadar dört seviyede sınıflandırırlar; bunlar sırasıyla uyanık, uykulu, stupor ve koma seviyeleridir. Bilinçsizliğin nedenleri çeşitli olmasına rağmen, doktorlar genellikle baskın yaklaşıma göre yapısal ve metabolik nedenler olarak ayırırlar. Yapısal koma için cerrahi müdahale, metabolik koma ise öncelikle tıbbi tedavi gerektirir. Bilincini yitiren hastaların tanısı ve yönetimi, özenli bir tıbbi öykü alımı ve genel tıbbi ve nörolojik muayeneleri içeren kapsamlı bir klinik değerlendirme gerektirir. ABC yaklaşımı ile hemen resüsitasyonun ve uygun yönetim protokollerinin ardından, doktorlar bilinç kaybının nedenlerini klinik kanıtlar ve tetkikler aracılığıyla aramalıdır. Uygun yönetim, bilincin bozulmasına bağlı ikincil komplikasyonlardan kaçınmaya yardımcı olacaktır. Bir komanın prognozu da çeşitli ve öncelikle etiyolojisine bağlıdır. Koma için prognoz algoritması, kötü sonuç belirleyicileri için yardımcıdır.
References
Arguinchona JH, Tadi P. Neuroanatomy, Reticular Activating System. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
Moruzzi G, Magoun HW. Brain stem reticular formation and activation of the EEG. Electroencephalogr Clin Neurophysiol. 1949 Nov;1(4):455-73.
Parvizi J, Damasio A. Consciousness and the brainstem. Cognition. 2001 Apr;79(1-2):135-60. doi: 10.1016/s0010-0277(00)00127-x.
Zeman A. Consciousness. Brain. 2001 Jul;124(Pt 7):1263-89. doi: 10.1093/brain/124.7.1263.
Reich JB, Sierra J, Camp W, Zanzonico P, Deck MD, Plum F. Magnetic resonance imaging measurements and clinical changes accompanying transtentorial and foramen magnum brain herniation. Ann Neurol. 1993 Feb;33(2):159-70. doi: 10.1002/ana.410330205.
Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: The FOUR score. Ann Neurol. 2005 Oct;58(4):585-93. doi: 10.1002/ana.20611.
Plum F, Posner JB. [The diagnosis of stupor and coma]. Brain Nerve. 2015 Mar;67(3):344-5.
Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46(7):2032-60. doi: 10.1161/STR.0000000000000069.
Greer DM, Yang J, Scripko PD, Sims JR, Cash S, Kilbride R, Wu O, Hafler JP, Schoenfeld DA, Furie KL. Clinical examination for outcome prediction in nontraumatic coma. Crit Care Med. 2012 Apr;40(4):1150-6. doi: 10.1097/CCM.0b013e318237bafb.
Bruno MA, Laureys S, Demertzi A. Coma and disorders of consciousness. Handb Clin Neurol. 2013;118:205-13. doi: 10.1016/B978-0-444-53501-6.00017-2.
Kislitsina ON, Rich JD, Wilcox JE, Pham DT, Churyla A, Vorovich EB, Ghafourian K, Yancy CW. Shock - Classification and Pathophysiological Principles of Therapeutics. Curr Cardiol Rev. 2019;15(2):102-113. doi: 10.2174/1573403X15666181212125024.
Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Confusion, Stupor, and Coma. Harrison’s Manual of Medicine. McGrawHill Education: New York, NY. 2016.
Olson KR. Poisoning. In: Papadakis MA, McPhee SJ, Rabow MW (ed) Current Medical Diagnosis & Treatment 2017. McGraw-Hill Education: New York, NY. 2016.
Masharani U. Diabetes Mellitus & Hypoglycemia. In: Papadakis MA, McPhee SJ, Rabow MW (ed) Current Medical Diagnosis & Treatment 2018. McGraw-Hill Education: New York, NY. 2017.
Mihic SJ, Koob GF, Mayfield J, Harris RA. Ethanol. In: Brunton LL, Hilal-Dandan R, Knollmann BC (ed) Goodman & Gilman’s: The Pharmacological Basis of Therapeutics. McGraw-Hill Education: New York, NY. 2017.
Ghany MG, Hoofnagle JH. Approach to the Patient with Liver Disease. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson JL, Loscalzo J (ed) Harrison’s Principles of Internal Medicine. McGraw-Hill Education: New York, NY. 2015.
Ropper AH, Samuels MA, Klein JP. Chapter 17. Coma and Related Disorders of Consciousness. Adams and Victor’s Principles of Neurology. 10th edn. The McGraw-Hill Companies: New York, NY. 2014.
Olson KR, Anderson IB, Benowitz NL, Blanc PD, Clark RF, Kearney TE, et al. Comprehensive Evaluation and Treatment. Poisoning & Drug Overdose. 7th edn. McGraw-Hill Education: New York, NY. 2017.
Simon RP, Aminoff MJ, Greenberg DA. Coma. Clinical Neurology. McGraw-Hill Education: New York, NY. 2017.
Santistevan J, Long B, Koyfman A. Rash Decisions: an Approach to Dangerous Rashes Based on Morphology. The Journal of Emergency Medicine. 2017; 52: 457–471.
Tan J, Fedi M. Clinical approach to comatose patients. Anaesthesia & Intensive Care Medicine. 2016; 17: 607–610.
Greer DM, Yang J, Scripko PD, Sims JR, Cash S, Wu O, et al. Clinical examination for prognostication in comatose cardiac arrest patients. Resuscitation. 2013; 84: 1546–1551.
Grmec Š, Gašparovic V. Comparison of APACHE II, MEES and Glasgow Coma Scale in patients with nontraumatic coma for prediction of mortality. Critical Care. 2001; 5: 19.
Barlow P. A practical review of the Glasgow Coma Scale and Score. The Surgeon. 2012; 10: 114–119.
Sternbach GL. The Glasgow Coma Scale11Medical Classics is coordinated by George Sternbach, MD, of Stanford University Medical Center, Stanford, California. The Journal of Emergency Medicine. 2000; 19: 67– 71.
Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. The Lancet Neurology. 2014; 13: 844–854.
Bajekal R, Bari F. Eye signs in anaesthesia and intensive care medicine. Anaesthesia & Intensive Care Medicine. 2017; 18: 44–46.
Wilhelm H. Disorders of the pupil. Handbook of Clinical Neurology. 2011; 102: 427–466.
Pullen RL. Clinical do’s & don’ts. Checking for oculocephalic reflex. Nursing. 2005; 35: 24.
Rzewnicki I, Łebkowski W, Kordecki JK. Evaluation of vestibulo-ocular reflex in patients with damage to the central nervous system (GCS score 5–3). Advances in Medical Sciences. 2015; 60: 107–111.
Greer DG, Donofrio PD. CHAPTER 16 - Electrophysiological Evaluations. In: Dobbs MR (ed) Clinical Neurotoxicology (201–212.). W.B. Saunders: Philadelphia. 2009.
Howard RS. Coma and brainstem death. Medicine. 2012; 40: 500–506.
Zubler F. Koenig C. Steimer A, et al. Prognostic and diagnostic value of EEG signal coupling measures in coma. Clinical Neurophysiol. 2016;127:2942–52.
Giza C. Hovda D. The new neurometabolic cascade of concussion. Neurosurgery. 2014;75:S24–33.
Horsting M. Franken M. Meulenbelt J. van Klei W. de Lange D. The etiology and outcome of non-traumatic coma in critical care: a systematic review. BMC Anesthesiol. 2015;15:65.
Forsberg S. Hojer J. Ludwigs U. Prognosis of patients presenting with nontraumatic coma. J Emerg Med. 2012;42:249–53.
Sacco R. Van Gool R. Mohr JP. Hauser WA. Nontraumatic coma. Glasgow Coma Score and coma etiology as predictors of 2 week outcome. Arch Neurol. 1990;47:1181–4.
Moruzzi G, Magoun HW. Brain stem reticular formation and activation of the EEG. Electroencephalogr Clin Neurophysiol. 1949 Nov;1(4):455-73.
Parvizi J, Damasio A. Consciousness and the brainstem. Cognition. 2001 Apr;79(1-2):135-60. doi: 10.1016/s0010-0277(00)00127-x.
Zeman A. Consciousness. Brain. 2001 Jul;124(Pt 7):1263-89. doi: 10.1093/brain/124.7.1263.
Reich JB, Sierra J, Camp W, Zanzonico P, Deck MD, Plum F. Magnetic resonance imaging measurements and clinical changes accompanying transtentorial and foramen magnum brain herniation. Ann Neurol. 1993 Feb;33(2):159-70. doi: 10.1002/ana.410330205.
Wijdicks EF, Bamlet WR, Maramattom BV, Manno EM, McClelland RL. Validation of a new coma scale: The FOUR score. Ann Neurol. 2005 Oct;58(4):585-93. doi: 10.1002/ana.20611.
Plum F, Posner JB. [The diagnosis of stupor and coma]. Brain Nerve. 2015 Mar;67(3):344-5.
Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Jul;46(7):2032-60. doi: 10.1161/STR.0000000000000069.
Greer DM, Yang J, Scripko PD, Sims JR, Cash S, Kilbride R, Wu O, Hafler JP, Schoenfeld DA, Furie KL. Clinical examination for outcome prediction in nontraumatic coma. Crit Care Med. 2012 Apr;40(4):1150-6. doi: 10.1097/CCM.0b013e318237bafb.
Bruno MA, Laureys S, Demertzi A. Coma and disorders of consciousness. Handb Clin Neurol. 2013;118:205-13. doi: 10.1016/B978-0-444-53501-6.00017-2.
Kislitsina ON, Rich JD, Wilcox JE, Pham DT, Churyla A, Vorovich EB, Ghafourian K, Yancy CW. Shock - Classification and Pathophysiological Principles of Therapeutics. Curr Cardiol Rev. 2019;15(2):102-113. doi: 10.2174/1573403X15666181212125024.
Kasper DL, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. Confusion, Stupor, and Coma. Harrison’s Manual of Medicine. McGrawHill Education: New York, NY. 2016.
Olson KR. Poisoning. In: Papadakis MA, McPhee SJ, Rabow MW (ed) Current Medical Diagnosis & Treatment 2017. McGraw-Hill Education: New York, NY. 2016.
Masharani U. Diabetes Mellitus & Hypoglycemia. In: Papadakis MA, McPhee SJ, Rabow MW (ed) Current Medical Diagnosis & Treatment 2018. McGraw-Hill Education: New York, NY. 2017.
Mihic SJ, Koob GF, Mayfield J, Harris RA. Ethanol. In: Brunton LL, Hilal-Dandan R, Knollmann BC (ed) Goodman & Gilman’s: The Pharmacological Basis of Therapeutics. McGraw-Hill Education: New York, NY. 2017.
Ghany MG, Hoofnagle JH. Approach to the Patient with Liver Disease. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson JL, Loscalzo J (ed) Harrison’s Principles of Internal Medicine. McGraw-Hill Education: New York, NY. 2015.
Ropper AH, Samuels MA, Klein JP. Chapter 17. Coma and Related Disorders of Consciousness. Adams and Victor’s Principles of Neurology. 10th edn. The McGraw-Hill Companies: New York, NY. 2014.
Olson KR, Anderson IB, Benowitz NL, Blanc PD, Clark RF, Kearney TE, et al. Comprehensive Evaluation and Treatment. Poisoning & Drug Overdose. 7th edn. McGraw-Hill Education: New York, NY. 2017.
Simon RP, Aminoff MJ, Greenberg DA. Coma. Clinical Neurology. McGraw-Hill Education: New York, NY. 2017.
Santistevan J, Long B, Koyfman A. Rash Decisions: an Approach to Dangerous Rashes Based on Morphology. The Journal of Emergency Medicine. 2017; 52: 457–471.
Tan J, Fedi M. Clinical approach to comatose patients. Anaesthesia & Intensive Care Medicine. 2016; 17: 607–610.
Greer DM, Yang J, Scripko PD, Sims JR, Cash S, Wu O, et al. Clinical examination for prognostication in comatose cardiac arrest patients. Resuscitation. 2013; 84: 1546–1551.
Grmec Š, Gašparovic V. Comparison of APACHE II, MEES and Glasgow Coma Scale in patients with nontraumatic coma for prediction of mortality. Critical Care. 2001; 5: 19.
Barlow P. A practical review of the Glasgow Coma Scale and Score. The Surgeon. 2012; 10: 114–119.
Sternbach GL. The Glasgow Coma Scale11Medical Classics is coordinated by George Sternbach, MD, of Stanford University Medical Center, Stanford, California. The Journal of Emergency Medicine. 2000; 19: 67– 71.
Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G. The Glasgow Coma Scale at 40 years: standing the test of time. The Lancet Neurology. 2014; 13: 844–854.
Bajekal R, Bari F. Eye signs in anaesthesia and intensive care medicine. Anaesthesia & Intensive Care Medicine. 2017; 18: 44–46.
Wilhelm H. Disorders of the pupil. Handbook of Clinical Neurology. 2011; 102: 427–466.
Pullen RL. Clinical do’s & don’ts. Checking for oculocephalic reflex. Nursing. 2005; 35: 24.
Rzewnicki I, Łebkowski W, Kordecki JK. Evaluation of vestibulo-ocular reflex in patients with damage to the central nervous system (GCS score 5–3). Advances in Medical Sciences. 2015; 60: 107–111.
Greer DG, Donofrio PD. CHAPTER 16 - Electrophysiological Evaluations. In: Dobbs MR (ed) Clinical Neurotoxicology (201–212.). W.B. Saunders: Philadelphia. 2009.
Howard RS. Coma and brainstem death. Medicine. 2012; 40: 500–506.
Zubler F. Koenig C. Steimer A, et al. Prognostic and diagnostic value of EEG signal coupling measures in coma. Clinical Neurophysiol. 2016;127:2942–52.
Giza C. Hovda D. The new neurometabolic cascade of concussion. Neurosurgery. 2014;75:S24–33.
Horsting M. Franken M. Meulenbelt J. van Klei W. de Lange D. The etiology and outcome of non-traumatic coma in critical care: a systematic review. BMC Anesthesiol. 2015;15:65.
Forsberg S. Hojer J. Ludwigs U. Prognosis of patients presenting with nontraumatic coma. J Emerg Med. 2012;42:249–53.
Sacco R. Van Gool R. Mohr JP. Hauser WA. Nontraumatic coma. Glasgow Coma Score and coma etiology as predictors of 2 week outcome. Arch Neurol. 1990;47:1181–4.
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May 3, 2024
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Kocabaş Y. Bilinç Kaybı Olgusuna Acil Yaklaşım ve Ayırıcı Tanılar. In: Akman C, Karcıoğlu Ö, editors. Dahili Aciller [Internet]. Türkiye: Academician Publishing Book DOI Portal; 2024 [cited 2026 Jul. 13]. pp. 307-22. Available from: https://omp35.books.akademisyen.net/index.php/akya/catalog/book/3074/chapter/13182
