Coma

Question 1

What is coma?

Answer 1

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

Question 2

What does consciousness depend on?

Answer 2

Intact ascending reticular activating system - to give arousal
A functioning cerebral cortex of both hemispheres - to give awareness of environment

Question 3

What can cause low GCS?

Answer 3

Toxic/metabolic states
Seizures
Damage to reticular activating system
Causes of raised ICP

Question 4

What can cause raised ICP?

Answer 4

Tumour 
Stroke 
Epidural heamtoma 
Subdural haemorrhage 
Subarachnoid haemorrhage 
Hydrocephalus

Question 5

What is persistent vegetative state?

Answer 5

vegetative state is absence of responsiveness and awareness due to overwhelming dysfunction of the cerebral hemispheres, with sufficient sparing of the diencephalon and brain stem to preserve autonomic and motor reflexes and sleep-wake cycles

Question 6

What recovers in persistent vegetative state?

Answer 6

Brain stem

So there is arousal and wakefulness

Question 7

What is locked in syndrome?

Answer 7

Condition where damages part of the brainstem, in which the body and most of the facial muscles are paralysed but consciousness remains and the ability to perform certain eye movements is preserved

Question 8

Where does paralysis begin in locked in syndrome?

Answer 8

Below the level of CN III

Question 9

What can a patient do in locked in syndrome?

Answer 9

Has consciousness

and can perform certain eye movements

Question 10

What are the steps for resuscitation?

Answer 10

Airway
Breathing
Circulation

Question 11

What can depressed respiration tell you about coma?

Answer 11

Drug overdose

Metabolic disturbance

Question 12

What can increased respiration tell you about a patient?

Answer 12

Potential
hypoxia
Hypercapnia
acidosis

Question 13

What can fluctuating respiration tell you about a patient?

Answer 13

Potential brainstem lesion

Question 14

What blood samples should be done on admission?

Answer 14

glucose, biochemistry, haematology, blood gas

toxicology

Question 15

What should a coma patient be examined for?

Answer 15

Evidence of meningitis

Question 16

What basic tests should be carried out on a coma patient on admission (very basic)?

Answer 16

Baseline BP
Pulse
Temperature
IV access

Question 17

What should be monitored in a potential coma patient?

Answer 17

Temperature
Heart rate, Blood Pressure, CVS
Respiration
Skin, breath
Abdomen
Meningism potential 
Fundal examination

Question 18

How do you examine and assess a coma patient?

Answer 18

GCS
Brainstem function
Motor function and reflexes

Question 19

What are the 4 level of eye opening in GCS?

Answer 19

Spontaneous - 4
To speech - 3
To pain - 2
None - 1

Question 20

What are the 5 levels of verbal response in GCS?

Answer 20

Orientated - 5 
Confused - 4 
Inappropriate words - 3 
Incomprehensible sounds - 2 
None - 1

Question 21

What are the 6 levels of motor response for GCS?

Answer 21

Obeying commands - 6
Localising to pain - 5 
Withdrawing from pain - 4 
Flexing to pain - 3 
Extending to pain - 2 
None - 1

Question 22

What is the GCS for coma?

Answer 22

< or equal to 8

Question 23

What is eye opening score in coma?

Answer 23

2 or less

Question 24

What is verbal response score in coma?

Answer 24

2 or less

Question 25

What is motor response in coma?

Answer 25

4 or less

Question 26

Which cranial nerves control pupillary reactions?

Answer 26

II and III

Question 27

Which cranial nerves control corneal responses?

Answer 27

V and VII

Question 28

Which cranial nerves control eye movements?

Answer 28

CN III, IV, VI

Question 29

Which cranial nerves control oculovestibular responses?

Answer 29

III, IV, VI , VII

Question 30

Which factors affecting the prediction outcome for coma?

Answer 30

``` Age Cause of coma Depth of coma Duration of coma Certain clinical signs the most important of which are brainstem reflexes ```

Question 31

What care need to continued for a patient in a coma?

Answer 31

``` Maintenance of vital functions Care of skin - avoidance of pressure sores Attention to bladder and bowel function Control of seizures Prophylaxis of DVT, peptic ulceration Prevention of contractures Consider the “Locked - in” Syndrome ```

Question 32

Which head injuries can lead to focal neurological signs/epilepsy?

Answer 32

``` Diffuse axonal injury Contusion Intracerebral haematoma Extra-cerebral haematoma Extra-dural haematoma Sub-dural haematoma ```

Question 33

How do you treat raised ICP?

Answer 33

Surgery to relieve the pressure Osmotic agents Maintain good PO2 and reduce PCO2 Reduce the pain

Question 34

What investigations are obligatory for coma/

Answer 34

CT or MRI

Question 35

Which other investigations can be done for coma patients?

Answer 35

Metabolic screens LP EEG

Question 36

What can cause a coma without focal or lateralising signs and without meningism?

Answer 36

Anoxic/ ischaemic conditions Metabolic disturbances Intoxications Systemic infections Epilepsy

Question 37

What investigations should be done forcoma without focal or lateralising signs and without meningism?

Answer 37

``` Toxicology screen including alcohol level Measure blood sugar and electrolytes Assess hepatic and renal function Acid - base assessment and blood gases Measure blood pressure Consider carbon monoxide poisoning ```

Question 38

What are some causes of coma without focal or lateralising signs but with meningism?

Answer 38

SAH Meningitis Encephalitis

Question 39

What investigations should be done forcoma without focal or lateralising signs but with meningism?

Answer 39

CT | LP

Question 40

What things should be assessed on LP?

Answer 40

Appearance Cell count Glucose level Capsular antigen test

Question 41

What can cause Coma with focal brainstem or lateralising cerebral signs?

Answer 41

Cerebral tumour Cerebral haemorrhage Cerebral infarction Cerebral abscess

Question 42

What investigations should be done for coma with focal brainstem or lateralising cerebral signs?

Answer 42

``` CT or MRI obligatory If not diagnostic investigate: Metabolic screens LP EEG ```

Question 43

What % of patients in non-traumatic coma >6 hours will make a good recovery?

Answer 43

15% | Other 85% will die or remain in a state of vegetative/severe disability