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Nervous System > Coma > Flashcards

Coma Flashcards

1
Q

define coma?

A

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

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2
Q

what is the glasgow coma scale?

A

measures coma in patients

mild 13-15
moderate 9-12
severe - 3-8

3 = coma

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3
Q

what 2 things is conciousness dependent upon?

A

an intact ascending reticular activating system to act as the alerting or awakening element of consciousness

a functioning cerebral cortex of both hemispheres which determines the content of that consciousness

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4
Q

what is responsible for arousal in conciousness?

A

Reticular activating system

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5
Q

what is responsible for awareness of environment in conciousness?

A

Cerebral hemispheres

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6
Q

what are causes of reduced GCS?

A

Toxic/metabolic states
Hypoxia/hypercapnia/sepsis/hypotension
Drug intoxication/renal or liver failure
Hypoglycaemia, ketoacidosis

Seizures

Damage to reticular activating system

Causes of raised intracranial pressure
tumour, stroke, EDH, SDH, SAH, hydrocephalus

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7
Q

what are examples of toxic/metabolic states?

A

Hypoxia/hypercapnia/sepsis/hypotension

Drug intoxication/renal or liver failure

Hypoglycaemia, ketoacidosis

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8
Q

what are causes of raised intracranial pressure?

A

tumour, stroke, EDH, SDH, SAH, hydrocephalus

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9
Q

what is first line management for resusitation?

A

Airway
Breathing
Circulation

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10
Q

what does depressed respiration indicate?

A

drugs overdose
metabolic disturbance

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11
Q

what does increased respiration indicate?

A

hypoxia
hypercapnia
acidosis

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12
Q

what does fluctuating respiration indicate?

A

brainstem lesion

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13
Q

following ABC what should be done further in a hospital setting?

A

blood samples

baseline bp, pulse, temp, IV acsess, neck stabalised

examine for evidence of meningitis

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14
Q

what is a persistent vegetative state?

A

A state in which the brain stem recovers to a considerable extent but there is no evidence of recovery of cortical function

There is arousal and wakefulness but the patient does not regain awareness or purposeful behaviour of any kind

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15
Q

what should be asked in the history of a patient experiencing coma?

A

? Predictable progression of underlying illness

? Unpredictable event in patient with previously known disease

? Totally unexpected event
? Head injury, sudden collapse, limb twitching, previous history of drug or alcohol abuse

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16
Q

what should be monitored and examined in a coma patient?

A

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

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17
Q

what are neurological assessments of coma?

A

Glasgow Coma Scale

Brainstem Function

Motor Function + Reflexes

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18
Q

how is eye opening measure in GCS?

A

Spontaneous 4
To speech 3
To pain 2
None 1

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19
Q

how is best verbal response measured in GCS?

A

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

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20
Q

how is best motor response measured in GCS?

A

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

21
Q

what cranial nerves are responsible for pupillary reactions?

A

II + III

22
Q

what cranial nerves are responsible for corneal responses?

A

V+VII

23
Q

what cranial nerves are responsible for spontaneous eye movements?

A

III, IV, VI

24
Q

what cranial nerves are responsible for oculocephalic responses (Doll’s eye)?

A

III, IV, VI, VIII

25
Q

what cranial nerves are responsible for Oculovestibular responses?

A

III, IV, VI, VIII

26
Q

what cranial nerves are responsible for Respiratory pattern?

A

Medullary centre

27
Q

how is motor function tested?

A

Motor response
Muscle tone
Tendon reflexes
Seizures (twitching posturing on limbs)

28
Q

Coma without focal or lateralising signs and without meningism?

A

Anoxic/ ischaemic conditions
Metabolic disturbances
Intoxications
Systemic infections
Hyperthermia/ Hypothermia
Epilepsy

29
Q

what are investigations for Coma without focal or lateralising signs and without meningism?

A

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

30
Q

Coma without focal or lateralising signs but with meningism?

A

Subarachnoid Haemorrhage

Meningitis

Encephalitis

31
Q

investigations for Coma without focal or lateralising signs but with meningism?

A

CT head scan

Lumbar puncture
Appearance
Cell count
Glucose level
Capsular antigen tests

32
Q

Coma with focal brainstem or lateralising cerebral signs?

A

Cerebral tumour

Cerebral haemorrhage

Cerebral infarction

Cerebral abscess

33
Q

Investigations for Coma with focal brainstem or lateralising cerebral signs?

A

CT or MRI obligatory

If CT/MRI not diagnostic, then investigate as for other causes of coma e.g. including
metabolic screens
lumbar puncture
EEG

34
Q

“Medical” causes of coma lasting more than 5 hours?

A

40% due to drug ingestion ± alcohol

25% due to hypoxia e.g. secondary to MI

20% due to cerebrovascular event, either haemorrhage or infarction

15% metabolic e.g. diabetes, hepatic failure, renal failure, sepsis, hypercapnia/hypoxia

35
Q

what is locked in syndrome?

A

patient has total paralysis below level of nthird nerve nuclei and although able to open elevate and depress eyes has no horizontal eye movement and no other voluntary eye movement

diagnosis depends on recognising that patient can open eyes voluntarily and signal numerically by eye closure

36
Q

what factors affect prediction of outcome in coma?

A

Age
Cause of coma
Depth of coma
Duration of coma
Certain clinical signs, the most important of which are the brain stem reflexes

37
Q

Prediction of Outcome in Coma in non traumatic coma?

A

Overall, only 15% of patients in non-traumatic coma for more than 6 hours will make a good or moderate recovery, the other 85% will die, remain vegetative or reach a state of severe disability in which they remain dependent

38
Q

how is recovery in non traumatic cober > 6 H?

A

In non-traumatic coma >six hours, good recovery is seen in
35% of those with underlying metabolic cause

11% of those with hypoxic ischaemic insult

7% of those with cerebrovascular disease

39
Q

how should care be continued for coma patients?

A

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

40
Q

how can head injury leas to focal neurological signs/ epilepsy?

A

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

41
Q

how does subdural haematoma present on CT?

A

Subdural haematoma ellipse
convex/convex

42
Q

how does extradural haematoma present on CT?

A

Extradural haematoma
concave/convex (lens)

43
Q

how should a head injury be managed?

A

Stabilise cervical spine
Airway/Breathing/Circulation
If GCS≤8 - intubation+ventilation
Treat raised ICP
Cranial imaging - may need decompressive surgery or removal of haematoma
Neuro observation

44
Q

how is raised intracrainial presssure treated?

A

Surgery to relieve pressure
heamatoma, ventricular shunt
Osmotic agents e.g. mannitol
Nurse with head at 30-45% (Venous return)
Reduce pain
Maintain good PO2, reduce PCO2
Reduce metabolism (reduce temperature, barbiturates)

45
Q

what are clinical features of non epileptc attacks?

A

sinusoidal tremour not jerking
pelvic thrusting
side to dide head movements
eyes closed and resist openong
partial responsivness

46
Q

what is the rosier scale used for?

A

It was created to aid first-line ER providers in determining which patients were likely experiencing a stroke, thus expediting referral to an acute stroke team. When compared to similar scales, such as the FAST, the ROSIER scale had greater sensitivity in acute stroke recognition.

47
Q

what is a hemicraniectomy

A

decompressive surgeryf for severe cerebral swelling post stroke

GCS fails 24-72 hour post stroke

48
Q
A

Nervous System (40 decks)

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