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COMA + Assessing Obtunded Patient Flashcards

(61 cards)

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1
Q

What is a coma

A

GCS <8

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2
Q

What is GCS score made up of

A

Eye opening /4
Verbal response / 5
Motor response / 6

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3
Q

How is eye opening graded

A

4 - spontaneous
3 - speech
2 - pain
1 - no response

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4
Q

How is verbal response graded

A 
5 - orientated
4 - confused 
3 - inappropriate words
2 - sounds
1 - no response
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5
Q

How is motor response graded

A

6 - obeys commands (e.g. stick out tongue)

Apply supra-orbital pressure
5 - localised to pain - hand above clavicle
4 - flexion withdraws (normal) - above and away from body / stimulus
3 - abnormal flexion (decorticate) - corticospinal - elbow bends and hand comes across body
2 - abnormal extension (decerebrate) - brain stem typically pontine or herniation - elbow starts to extend backwards
1 - no response

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6
Q

What are causes of decreased GCS

A 
Metabolic 
Toxins
Trauma
Ischaemic 
Infection
Systemic 
Raised ICP 
Damage to reticular activating system 
Seizures
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7
Q

What are metabolic / toxic causes

A 
Hypoxia
Hypothermia 
Sepsis
Drugs
Renal / liver failure
Hypoglycaemia
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8
Q

What are toxic causes

A

Drugs

CO poisoning

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9
Q

What would cause no focal or menngism signs

A 
Ischaemia
Metabolic
Infection
Systemic
Epilepsy
Hypothermia
Toxins
Trauma
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10
Q

What would cause menngism

A

Menignitis

SAH

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11
Q

What would cause focal

A

Tumour
Haemorrhage
Abscess
Infarction

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12
Q

How do you initially manage coma

A 
Resus
ABCDE
Stabilise neck
Examination
Send bloods
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13
Q

When would breathing be depressed

A

Drug - opiates

Metabolic

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14
Q

When would breathing be increased

A

Hypoxia

Acidosis

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15
Q

What would cause fluctuating breathing

A

Brain stem

Raised ICP

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16
Q

What else do you examine

A

GCS
Brain stem function
Motor function and reflexes

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17
Q

What do you do if no focal or meningitis signs

A 
Tox screen
Blood sugar
Hepatic and renal function
BP 
Blood gas
CO poison
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18
Q

What if no focal but meningitic signs

A

CT

LP

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19
Q

What do you do if focal signs

A

CT / MRI

LP

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20
Q

What tests brain stem function

A 
Pupils
Corneal response
Eye movement
Oculocephalic reflex
Oculovestibular reflex
Resp pattern
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21
Q

What is oculocephalic response

A

Eyes move with head tilt

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22
Q

What is oculovestibular response

A

Nystagmus

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23
Q

What CN is pupil response checking

A

2+3

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24
Q

Corneal response

A

5+7

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25
Eye movements
3,4,6
26
Eye reflexes
3,4,6,8
27
Resp patterm
Medulla
28
What affects outcome
Age Cause Duration Brain stem reflexes
29
What is change of recovery in traumatic coma >6 hours
15%
30
What is Locked in
Damage to front of pons where spinothalamic tract passes Causes total paralysis below 3rd CN Can only open and depress eyes and breath No other movement
31
How do you treat coma
``` Maintain vital functions Skin care Bladder + bowel Control seizures DVT prophylaxis Prevent contractures Consider locked in ```
32
If pupils bilateral dilated what does this suggest
Cerebral herniation crushing optic nerve as bilateral defect Irreversible Unopposed dilator pupillae
33
What does unilateral dilated pupil suggest
Problem with oculomotor nerve (III)
34
What is important to know when assessing obtunted patient
``` Lobe of brain affected Is cerebellum affected Are CN affected Is there spinal cord damage Is there peripheral nerve damage ```
35
What do you want to know about spinal cord damage
What level Myelopathy Radiculopathy
36
What is frontal lobe responsible for
``` Voluntary control of movement Speech - BROCA's Saddaic eye movement Bladder control Memory Gait ```
37
What does SMA do
Higher order functions such as initiative / apathy / motivation Civil and approropiate behaviour
38
What does prefrontal cortex do
``` Integrates sensory info Generate response to environmental changes Select most appropriate response Maintain set task Order data etc ```
39
What can you do if frontal cortex in tact
Make appointments Give coherent Hx Spell words backward Say as many words beginning with letter
40
What is parietal lobe responsible for
``` Primary sensory centre Body image representation Awareness of body Visualspatial coordination Language Numeracy ```
41
What is superior lobe used for
Awareness of contralateral half of body | SAA
42
What is inferior lobe for
Visual | Auditory
43
What is cortical sensory syndrome
Sensory inattention Agnosia Asteroagnosia Two point discrimination
44
If damage on dominant side of parietal lobe
Dyscalcui L/R disorientation Agrpahia Finger anomia
45
If on non-dominant side
Hemi-neglect Apraxia Ideomotor apraxia Loss of spatial awareness
46
What is temporal lobe response for
``` Bilateral process of auditory input LANGUAGE Wernicke's - understanding Long term memory Emotion Perception of moving objects / recognising phases ```
47
What is responsible for long term memory
Hippocampus
48
What is responsible for emotion
Amygdala
49
What is occipital lobe responsible for
Visual field
50
Where does optic radiation travel through
Parietal and occipital lobe
51
What does cerebellar damage cause
``` Dysdisdochokinesia Ataxia Nystagmus Inattention tremor Slurred speech - baby hippocampus / scanning dysarthria Hypotonia Past pointing ```
52
How do you test
Finger nose test Knee heel test Walk in straight line
53
When do test for brain death
If in deep coma with known aetiology Reversbile causes excluded No sedation Normal electrolyte levels
54
Who can test
``` 2+ doctors 5+ post grad expereince At least one consultant Must not be a member of transplant team Must test 5 hours apart ```
55
What is done to test for brain death
``` Fixed dilated pupils No corneal reflex No oculovestibular reflex No response to suborbital pressure No cough reflex to bronchial stimulation No gag reflex to pharyngeal stimulation No resp effort when ventilator off >5 mins to allow pCO2 to rise >6 ```
56
What is brainstem responsible for
``` 10/12 cranial nerve Major eye movement Breathing HR Swallowing Consciousness ```
57
What motor if brain stem damaged
Contralateral hemiparesis due to tracts crossing over
58
When do you intubate
GCS <8
59
Quick test for CSF
Glucose CSF contains Mucous does not
60
Decorticate posturing
Due to lesion above the red nucleus
61
Decerebrate
Lesion below red nucleus | Usually brain stem / pontine stroke

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