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Coma, conscience & mort cérébrale
Steven LAUREYS
Coma Science GroupGIGA & Neurology DeptUniversité & CHU de Liège
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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
“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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