Coma and Vegatative State

Question 1

what is coma?

Answer 1

a state of unrousable psychological unresponsiveness in which in which subjects lie with eyes closed and show no psychologically understandable response to external stimulus or inner need

Question 2

what acts as the alerting or awakening element of consciousness?

Answer 2

intact ascending reticular activating system

Question 3

what could cause a decrease in the glasgow coma score?

Answer 3

> toxic/metabolic states
seizures
damage to reticular activating system
increased intracranial pressure

Question 4

what toxic or metabolic states could cause a decrease in Glasgow coma score?

Answer 4

> hypoxia
> hypercapnia
> sepsis
> hypotension
> drugs intoxication
> renal/liver failure
> hypoglycaemia
> ketoacidosis

Question 5

does focal damage to part of the cortex affect the conscious level?

Answer 5

no

Question 6

what is persistent vegetative state?

Answer 6

a state in which the brain stem recovers to a considerable extent but there is no evidence of recovery or cortical function.
there is arousal/wakefulness but no awareness or purposeful behaviour.

Question 7

below what level is paralysed in locked in syndrome?

Answer 7

below the level of the third nerve nulcei

Question 8

how can someone in locked in syndrome move their eyes?

Answer 8

> open their eyes
elevate
depress

Question 9

how is locked in syndrome diagnosed?

Answer 9

the patient can open their eyes voluntarily and signal numerically by eye closure.

Question 10

what causes locked in syndrome?

Answer 10

damage to the pons

Question 11

what tests/examinations could you carry out in resuscitation?

Answer 11

> blood glucose
> blood gas
> toxicology
> blood pressure
> pulse
> temperature
> look for evidence of meningitis (treat on suspicion)

Question 12

what is needed to be examined and monitored?

Answer 12

> temperature
> heart rate, blood pressure, CVS
> respiration
> skin
> abdomen
> meningism
> fundal examination

Question 13

how is a coma neurologically assessed?

Answer 13

> Glasgow coma scale
brainstem function
motor function and reflexes

Question 14

describe eye opening in the glasgow coma scale?

Answer 14

> spontaneous: 4
to speech 3
to pain: 2
none: 1

Question 15

describe the scoring of best verbal response in the GCS

Answer 15

> orientated: 5
> confused: 4
> inappropriate words:3
> incomprehensible sounds: 2
> none: 1

Question 16

describe the scoring of the best motor response on the GCS

Answer 16

> obeying motor response 6
> localising to pain 5
> withdrawing from pain 4
> flexing to pain 3
> extending to pain 2
> none 1

Question 17

describe the GCS of someone in a coma

Answer 17

> eye opening 2 or less
verbal response 2 or less
motor response 4 or less
GCS less than or equal to 8

Question 18

what cranial nerves are involved in pupillary reactions?

Answer 18

2 and 3

Question 19

what cranial nerves are involved in corneal response?

Answer 19

5 and 7

Question 20

what part of the brainstem is involved in respiratory pattern?

Answer 20

medullary centre

Question 21

name some causes of a coma without: focal or lateralising signs, meningism

Answer 21

> ischaemic conditions
> metabolic disturbances
> intoxications
> systemic infections
> hyperthermia/hypothermia
> epilepsy

Question 22

what investigations would you carry out in a coma without focal or lateralising signs or meningism?

Answer 22

> toxicology screen (including alcohol)
> blood sugar and electrolytes
> asses hepatic and renal function
> acid-base assessment and blood gases
> blood pressure
> (consider CO poisoning)

Question 23

what could cause a coma without focal or lateralising signs but WITH meningism?

Answer 23

> subarachnoid haemorrhage
meningitis
encephalitis

Question 24

what investigations would you carry out in a coma without focal or lateralising signs but WITH meningism?

Answer 24

> CT head scan
> Lumbar puncture:
- appearance
- cell count
- glucose level
-capsular antigen tests

Question 25

what could cause a coma with focal brainstem or lateralising cerebral signs?

Answer 25

> cerebral tumour
cerebral haemorrhage
cerebral infarction
cerebral abscess

Question 26

what investigations would you carry out for a coma with focal brainstem or lateralising cerebral signs?

Answer 26

> CT or MRI is obligatory
> If CT or MRI is not diagnostic then investigate other causes e.g.:
- metabolic screens
> lumbar puncture
> EEG

Question 27

what is the most common medical cause for a coma lasting for more than 5 hours?

Answer 27

drug ingestion including alcohol

Question 28

what factors can affect the outcome of a coma?

Answer 28

>age
> cause
> depth of coma
> duration
> clinical signs, including brainstem reflexes

Question 29

how many patients will make a good recovery in a non-traumatic coma for 6 hours or more?

Answer 29

15% of patients

Question 30

in a non-traumatic coma lasting more than 6 hours when in good recovery seen?

Answer 30

> 35% with underlying metabolic cause
11% hypoxic ischaemic insult
7% cerebrovascular disease

Question 31

describe the continuing care of patients in coma

Answer 31

> maintenance of vital functions
> care of skin
> attention to bladder and bowel function
> control of seizures
> DVT and peptic ulceration prophylaxis
> prevention of contractures
> consider locked in syndrome

Question 32

what can head injury cause that leads to focal neurological signs/epilepsy?

Answer 32

> diffuse axonal injury
> contusion
> intracerebral haematoma
> extra-cerebral haematoma:
- extra dural
-sub dural

Question 33

describe the management of head injury

Answer 33

> stabilise cervical spine
> ABC's
> intubation and ventilation (GCS less than 8)
> treat raised ICP
> cranial imaging
> neuro observation

Question 34

how would you treat raised ICP?

Answer 34

> surgery to relieve pressure
> osmotic agents
> nurse at 30-54%
> reduce pain
> maintain good PO2
> reduce metabolism