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    Coma, conscience & mort crbrale

    Steven LAUREYS

    Coma Science GroupGIGA & Neurology DeptUniversit & CHU de Lige

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    docteur, je suis mort

    Karnice-Karnicki, 1896

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    docteur, je suis mort

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    Brve histoire du coma

    Bjrn Ibsen Copenhagen 1952 Pius XII (1957)

    Respirateur artificiel

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    Mort clinique mortTransplants - Are the donors really dead ?

    Depuis les annes 50s aucuun patient avec les criteres de mort crbrale a recuper conscience

    (Laureys, Nature Reviews Neuroscience 2005)

    1980

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    Mort crbrale = mort

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    Mort crbrale = mort

    CONSCIENCENORMALE

    MORTCEREBRALE

    CARDIAC ARREST

    Laureys, Nature Reviews Neuroscience, 2005

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    Mort clinique mort

    CONSCIENCENORMALE

    MORTCEREBRALE

    ARRETCARDIAQUE

    Laureys, Nature Reviews Neuroscience, 2005

  • docteur, jai eu une exprience de mort imminente

    Towards a neuro-scientific explanation of Near-Death Experiences?Vanhaudenhuyse, Thonnard, Laureys 2009 Yearbook of Intensive Care and Emergency Medicine Springer-Verlag

    Hieronymus Bosch 1500s Visions de lau del

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    dcorporation

    Blanke et al Stimulating illusory own-body perceptions. Nature, 2002 (6904)269-70De Ridder et al Visualizing out-of-body experience in the brain. N Engl J Med, 2007 (357) 1829-1833

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    Experience de Mort Imminente

    Charland et al, Front Hum Neurosci 2014

    99% positive1% negative

    140 coma- anoxique (45)- traumatique (30)- autre(65)

    50 pas de coma

    *

    **

    *

    *

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    How to examine brain death

    Avoiding diagnostic error in brain deathLaureys & Fins Neurology 2008 70(4) 14-5

    Diagnostic criteria (AAN 2010)

    - Demonstration of coma

    - Evidence for the cause of coma

    - Absence of confounding factors, including hypothermia, drugs, electrolyte, and endocrine disturbances

    - Absence of brainstem reflexes

    - Absent motor responses

    - Apnea

    - A repeat evaluation in 6h is advised, but the time period is considered arbitrary

    - Confirmatory laboratory tests are only required whenspecific components of the clinical testing cannot bereliably evaluated

    APNEA test:

    Preoxygenation : inspired O2 1.0 for 10 minPO2>200 mm Hg, PCO2>40 mm Hgdisconnect, apneic diffusion oxygenation 6l/min O2observe >8 min, PCO2>60 mm Hg

    Bedside diagnosis

    AdaptedfromWijdicks,NEJM2001

    No response to pain

    No brainstem reflexes

    No spontaneous breathing

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    disorders of consciousness | behavioural evaluation | electrophysiology | neuroimaging | methods, ethics & quality of life | perspectives

    EEG

    isoelectrical or flat burst-suppression

    Brain death95% sensitivity95% specificity

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    POST-ANOXIC COMA

    MMN on auditory EPsN20 present

    exclude confounding factors including hypothermia, drugs, electrolyte disturbances

    brainstem reflexes(pupillary, cornea, oculocephalic, cough)

    apnea testing

    absent and GCS 3/15

    BRAIN DEATH

    positive

    GOODOUTCOMEFP 0%

    (95% IC NA)

    N20 absent

    POOROUTCOME

    FP 0.7% (95% IC 0-3.7%)

    or

    generalized suppression ( 33 g/l

    or

    FP 0% (95% IC 0-3%)

    D1-3: somatosensory EPs

    present

    negative

    Adapted from Wijdicks et al, Neurology, 2006Boveroux et al, Ranimation, 2008 (French)

    ORGAN PROCUREMENT ORGANIZATION

    ORGAN PROCUREMENT ORGANIZATION

    Pittsburgh Protocolnon-heart-

    beating donor

    confirmatory tests:isoelectrical EEG or

    transcranial Doppler orangiography or

    SPECT

    IRREVERSIBLE COMAMajority of deaths related to physicians decision to withhold or withdraw treatment (Laureys, Nature Reviews Neurosci 2005)

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    Ethique & fin de vie

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    [email protected]