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Page 1: Coma, conscience & mort cérébrale - nicolas … · Coma, conscience & mort cérébrale ... 140 coma - anoxique (45) - traumatique (30) - autre(65) ... POST-ANOXIC COMA MMN on auditory

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Coma, conscience & mort cérébrale

Steven LAUREYS

Coma Science GroupGIGA & Neurology DeptUniversité & CHU de Liège

www.comascience.org

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“docteur, je suis mort”

Karnice-Karnicki, 1896

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“docteur, je suis mort”

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Brève histoire du «coma»

Bjørn Ibsen – Copenhagen 1952 Pius XII (1957)

Respirateur artificiel

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Mort clinique ≠ mortTransplants - Are the donors really dead ?

Depuis les années 50’s aucu’un patient avec les criteres de mort cérébrale a recuperé conscience

(Laureys, Nature Reviews Neuroscience 2005)

1980

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Mort cérébrale = mort

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Mort cérébrale = 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

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“docteur, j’ai eu une expérience 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 l’au delà

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«décorporation»

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 (<20 µV) or ‘burst supression’ EEG FP 3%

(95% IC 0.9-11%)

D1: myoclonus status epilepticus

or

FP 0% (95% IC 0-8.8%)

D3: M1 or M2 or no pupillary or cornea reflex

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

D1-3: serum NSE > 33 µg/l

or

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

D1-3: somatosensory EPs

present

negative

Adapted from Wijdicks et al, Neurology, 2006Boveroux et al, Réanimation, 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]