Flashcards in Coma, Cohen Deck (33):
1
most common causes of comas
cardiac pulmonary failure
drug alcohol overdose
severe derangements of oran function with abnormal serum chemistries of pH: hypoglycemis, renal failure etc
stroke or hemorrhage
cranial truma
infections
psychiatric pseudo coma or catatonia
2
how long for cardiac or pulm failure before in coma
5 minutes
hypoxic ischemic damage throughout brain
3
important part about addressing a comatose patient
learning the history
chornic conditions, drug use, psych disorder etc
4
what aspect of coma is important to Dx and prognosis
duration of coma
5
Immediate steps for comatose patient
stabilize ABC
BP perfusion check
peripheral or central IV line
intubation/ventilation if needed
look for evidence of trauma
Hx from witnesses, family etc
comprehensive labs like CBC and toxicology
check if any chance opiate overdose(give naloxone)
6
Decerebrate
arm and leg in extension
brainstem or thalamus injury
7
decorticate
arms flex legs extended
widespread damage to both hemispheres
8
posturings
posture of coma patient that indicates serious disorder
9
general neuro exam of comatose patient
observe:
spontaneous respiration or ventilator dependent
spontaneous movement, unilateral etc
abnormal movements like tremors or jerks
response to voice, physical stimulation or none
general appearance
10
Brainstem functions to check on comatose patient
pupillary light reaction
pupillary diameters
corneal reaction
eye movements
oculocephalic reflex
oculovestivular reflex
gag
11
pupillary light reaction
CN II and III
12
pupillary diameters
II III
13
corneal reacion
CN V VII
14
CN eyemovements
III IV VI
15
what is oculocephalic reflex
dolls eyes
eyes in opp direction of head turn if no inhibition of hemispheres
16
oculovestibular reflex
cold calorics
eyes deviate conjugately toward ear given ice water, nystagmus away
pons and medulla
or eye deviate away or ear with warm water nystagmus towards
17
first reflex usually to be lost
gag
18
last reflex to be lost
pupillary light reaction
19
Where are nuclei for CN III
top of brainstem in midbrain
20
what can compress CN III nuclei
if there is uncal herniation of ipsilateral and sometimes contralateral
21
what will it look like with compromise to nuclei of CN III
dilated unreactive pupil
can still move eye lateral
22
most important signs for prognostic indicator for comatose patient
pupillary reaction to light
spontaneous movements
23
what patients are exempt from 5% living after coma for 72 hours
trauma swelling, sedation from drug overdose, hypothermia, multiple missing brain stem reflexes
24
brain dead means what
legally dead
25
requirements for brain death
no evidence cerebral function
no response to stimulation
no movements
no vocalization
no evidence brainstem function
26
how to confirm loss of brainstem function
apnea test
ventilator turned off but 100% O2 still given
if CO2 rises to 60mmHg and there is no respiratory effort = brain dead
27
when to tell family about coma
right away
no matter what before 72 hours
28
families relieved to learn what of comatose patients
no pain or suffering
29
Tx brain death patients
no further Tx. Kept until organs can be taken if donator
30
Vegetative state
loss of cerebral hemispheres but maintenance of part or all of brainstem
31
vision in vegetative state
have gross vision but no specific response to what patient "sees"
32
Criteria for persistent vegetative state
>1 mo vegetative state
no awareness self surroundings
no meaningful communication
facial expressions not accurate to stimulation
sleep wake cycles can be intact
arm or leg movements but no voluntary control
CV function maintained
incontinent bowle and bladder
33