coma

Question 1

Define delirium

Answer 1

fluctuating confusion, inattention, misperceptions (illusions or hallucinations)

Question 2

Define stupor

Answer 2

a sleep-like state from which the patient can be aroused only by vigorous stimuli

Question 3

Define coma

Answer 3

– 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. GCS 8 or less

Question 4

Define decerebrate posturing.

Answer 4

•upper extremity extension with lower extremity extension (suggests lesion at upper brainstem)

Question 5

Define decorticate posturing.

Answer 5

•upper extremity flexion with lower extremity extension (suggests lesion at hemispheres)

Question 6

Which prognosis is worse, decerebrate or decorticate

Answer 6

decerebrate is worse

Question 7

Glasgow coma scale

Answer 7

Defines level of consciousness along 3 parameters:
eye opening, language function and bodily movement. Record best response. 15-13: mild TBI. 12-9: moderate TBI. 8-3: severe TBI/comaDefines level of consciousness along 3 parameters:
eye opening, language function and bodily movement. Record best response. 15-13: mild TBI. 12-9: moderate TBI. 8-3: severe TBI/coma

Question 8

GCS definition of coma

Answer 8

Unable to follow commands, speak any words or open either eye. 100% if GCS 3-7, 50% if 8, and 0% if 9-12

Question 9

Guidelines for determination of death

Answer 9

1. irreversible cessation of circulatory and respiratory function. OR 2. irreversible cessation of all functions of entire brain, including brain stem.

Question 10

Understand the criteria for establishing brain death.

Answer 10

1. Unresponsiveness (deep coma, GCS 3). 2. Cerebral motor responses are abset during application of painful stimulus. Spinal reflexes may be present, seizures or flexion/extension posturing may not. 3. Absent brainstem reflexes (pupils, corneal, cough, gag, respirations)

Question 11

cranial nerves involved in pupillary reflex

Answer 11

CN II and III

Question 12

Corneal reflex- cranial nerves involved

Answer 12

V and VII

Question 13

Oculocephalic reflex (dolls eyes) - CN involved?

Answer 13

CN VIII, III, IV and VI. Rotate the head quickly to one side and observe eyes (no movement of any kind with brain death)

Question 14

Oculovestibular Reflex (Cold Caloric Test)- CN involved? How is it performed?

Answer 14

CN VIII, III, IV, VI. Flush each external auditory canal with 20 ml ice water x 2 and observe (no movement in brain death)

Question 15

cough reflex- how is it performed and CN involved

Answer 15

CN X- suction trachea at carina. No cough in brain death

Question 16

Gag reflex- CN involved

Answer 16

CN IX and X

Question 17

Apnea test

Answer 17

Give 100% O2 by vent and maintain PCO2 at 40mmHg. Then, disconnect vent and give O2 by T piece. After 8 minutes, measure blood gas. If no respiratory effort observed and pCO2 is 20 or more mmHg higher than baseline, apnea test is positive (brain death)

Question 18

When are confirmatory tests performed

Answer 18

1. If BP or pulse not stabilized. 2. anatomy doesn’t allow exam. 3. Patient is young child (always if <1 yr)

Question 19

List confirmatory tests

Answer 19

cerebral angiogram, radionuclide scan (cerebral blood flow), EEG (flat line), CT angiogram, doppler blood flow, evoked responses

Question 20

What is conciousness

Answer 20

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