Coma - Kelly

Question 1

Delirium

Answer 1

Fluctuating confusion, inattention, misperceptions (illusions hallucinations).

Question 2

Stupor

Answer 2

A sleep-like state from which the person can be aroused only by a vigorous stimulus.

Question 3

Coma

Answer 3

GCS of 8 or less.

A sleep-like state where the patient is unresponsive to external stimuli, and there are no sleep-wake cycles. Usually lasts no more than 4 weeks.

Question 4

Decerebrate posturing. Describe the position, likely location of the lesion, and the severity as compared to decorticate posturing.

Answer 4

Abnormal EXTENSION of the upper extremity with extension of the lower extremity.

Suggests an UPPER BRAINSTEM lesion.

More severe (worse prognosis).

Question 5

Decorticate posturing. Describe the position, likely location of the lesion, and the severity as compared to decerebrate posturing.

Answer 5

Abnormal FLEXION of the upper extremity with extension of the lower extremity.

Suggests a HEMISPHERIC lesion.

Less severe (better prognosis)

Question 6

Abnormal EXTENSION of the upper extremity with extension of the lower extremity.

Answer 6

Decerebrate posturing

Question 7

Abnormal FLEXION of the upper extremity with extension of the lower extremity.

Answer 7

Decorticate posturing

Question 8

Which has a worse prognosis, decerebrate or decorticate posturing?

Answer 8

Decerebrate posturing.

Question 9

While assessing a comatose patient for a GCS score, you witness decerebrate posturing on the right side, and decorticate posturing on the left. Which should be reported in the GCS?

Answer 9

Decorticate posturing on the left side is the “best” (ie the better of the two) responses.

Therefore, you would report this in the overall total, for a motor score of 3.

Decerebrate would give a score of 2).

Question 10

A patient is unable to:

1. Follow commands
2. Speak any recognizable words
3. Open either eye

Describe his condition.

Answer 10

Comatose.

Question 11

Classify each of the following GCS scores by coma/no coma.
3-7 –>
8 –>
9-12 –>

Answer 11

3-7 –> coma by definition
8 –> 50/50 (half will be comatose, half not comatose)
9-12 –> NOT coma by definition

Question 12

Give the two criteria to pronounce someone dead:

Answer 12

(1) irreversible cessation of circulatory and respiratory functions
(2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead.

Question 13

What are the three broad criteria that must be met for a patient to qualify for “brain death”?

For these criteria to be valid, what additional stipulations apply?

Answer 13

1) Unresponsive. Patient has a GCS of 3.
2) Cerebrally modulated responses to pain are absent.
3) Cranial nerve responses are absent.

1) Body temp of 32.2 C (90F)–>not dead till you’re warm and dead
2) Negative tox screen
3) Adequate BP and pulse (Pulse >50, Systolic >90)
4) No voluntary movements or response to pain

Question 14

A patient with a GCS of 3, who is unresponsive to pain, and has appropriate perfusion and core temperature with a negative tox screen exhibits a positive Babinski sign and deep tendon reflexes.

Can this patient be declared brain dead?

Answer 14

No. You have not checked the cranial nerve responses.

However, the spinal reflexes are not considered to be brain activity as they are mediated through the spinal cord.

Question 15

What seven cranial nerve responses must be checked to declare a patient brain dead?

Answer 15

1. Pupillary light reflex
2. Corneal reflex
3. Oculocephalic reflex (VOR, doll’s eyes)
4. Oculovestibular reflex (Cold caloric test x2 each side)
5. Cough reflex
6. Gag reflex
7. Respiratory effort (apnea test)

Question 16

You shine a flashlight in a comatose patient’s eye. negative response would be….?

Which cranial nerves did you just check?

Answer 16

Negative response–> no pupillary constriction, direct or consensual

CN II, III

[1. pupillary light reflex]

Question 17

You touch a patient’s corneas bilaterally with a cotton swab. A negative response would be…?

Which cranial nerves did you just check?

Answer 17

Negative–> no blink response in either eye

CN V and VII

[2. Corneal reflex]

Question 18

You grasp a patient’s head and move it side to side. A negative response would be…?

What cranial nerves did you just check?

Answer 18

Negative response–> eyes track with head. No nystagmus, VOR, or tracking observed.

CN III, IV, VI, VIII

[3. Oculocephalic reflex]

Question 19

You perform cold caloric testing on a patient, putting 20cc of ice water into both ears. You repeat this procedure 2x. A negative response would be…?

What CN did you check?

Answer 19

Negative–> no movement of any kind in the eyes

CN III, IV, VI, VIII

[4. Oculovestibular reflex]

Question 20

You suction the trachea of a patient at the carina. A negative response would be…?

What cranial nerves did you check?

Answer 20

Negative–> no cough

CN X

[5. Cough reflex]

Question 21

You touch the back of a patient’s throat with a cotton swab, bilaterally. A negative response would be…?

What cranial nerve did you check?

Answer 21

Negative–> No gag reflex, no movement of any oral structure.

CN IX, X

[6. gag reflex]

Question 22

After checking to make sure the patient has not “tripped the vent” in the past 1-2 hours, you ventilate him for 10 minutes at 100% O2 saturation, running the pCO2 around 40 before removing the ventilator and inserting a nasal cannula with 6L O2/min. You observe and feel for respiratory effort. After 8 minutes, you check the blood and reconnect the ventilator. A negative response would be…?

What CN did you check?

Answer 22

Negative–> No respiratory effort was observed and the pCO2 is 20 or more mmHg higher than baseline, the apnea test is positive (brain death).

No specific CN mentioned. Theoretically this checks the reticular formation?

Question 23

Consciousness derives from the activation of the intralaminar nuclei of the thalamus by the reticular activating system which project from the reticular formation of the brainstem.

Answer 23

x

Question 24

Define loss of consciousness.

Answer 24

Paralytic coma must be witnessed by observer

Eyes are closed in a sleep-like state
Unresponsiveness to external stimuli
Last seconds-minutes-hours-days-weeks
Rarely lasts more than one month
Length of coma is correlated with outcome

Question 25

If Gloria hits her head on a tree in a forest and knocks herself out and nobody sees it happen, did was she ever unconscious?

Answer 25

No. Paralytic coma must be witnessed by observer.

Question 26

What differentiates a vegetative state from a coma?

Answer 26

Vegetative state – eyes open spontaneously; sleep-wake cycles resume but there is no evidence of perception, communication, or purposeful motor activity.

Question 27

A patient who has been in an ischemia-induced vegetative state for 3 months will likely never recover. True or false?

Answer 27

True.

Question 28

A patient who has been in a trauma induced VS for 3 months will likely never recover?

Answer 28

False. 12 months is considered the point at which trauma induced VS is almost certainly permanent.

Question 29

What differentiates a minimally conscious state from a vegetative state?

Answer 29

Minimally conscious state – eyes open spontaneously; sleep-wake cycles resume; arousal level may be normal at times; there are reproducible, even though inconsistent, behavioral displays of perception, communication, or purposeful motor activity.

Question 30

What might be seen on fMRI in a comatose patient vs. a conscious, healthy patient?

Answer 30

Healthy patient–> activity in the right part of the brain

Coma–> less activity, randomly scattered throughout the brain.