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Coma Flashcards

0
Q

Define awareness

A

The ability to have and the having of experience of any kind

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1
Q

What are the three main disorders of consciousness

A

Coma
Vegetative state (VS)
Minimally conscious state (MCS)

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2
Q

Define wakefulness

A

A state in which the eyes are open and there is a degree of motor arousal: it contrasts with sleep: a state of eye closure and motor quiescence

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3
Q

Define coma

A

The extreme of a graded continuum of impairment of consciousness, at the opposite pole, from full alertness and awareness… Incapable of sensing or responding… Little or no spontaneous movement…no evidence of mental activity.

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4
Q

What are the qualities of a coma

A

Absent wakefulness and awareness : untouchable, unresponsive, lasting >6 hrs

Unaware patient unresponsive to external stimuli
No response to painful stimuli
No normal sleep wake cycles
Does not initiate voluntary movements

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5
Q

What are the 6 alternations of consciousness

A 
Clouding of consciousness 
Confusion
Delirium 
Obtundation 
Stupor 
Coma
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6
Q

What is clouding of consciousness

A

Reduced wakefulness and attention, excitability and irritability

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7
Q

What is confusion

A

Misinterpreted stimulus associated with a shortened attention span

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8
Q

What is delirium

A

Disorientation , fear , irritability, misperception of sensory stimuli and (visual) hallucinations

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9
Q

What is obtundation

A

Mental blunting or torpidity

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10
Q

What is stupor

A

Rousable unresponsive ness

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11
Q

What are the 5 main causes of an altered awareness

A 
Hypoxia/ischaemic 
Metabolic and infective
Trauma
Structural brain diseases
Psychogenic
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12
Q

What’s part of the brain maintains arousal

A

Intralaminar nuclei of the thalamus

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13
Q

Stimulation of what area causes arousal

A

Posterior hypothalamus

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14
Q

Lesions in which regions are involved in MCS

A

Cuneus and precuneus association cortex

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15
Q

Anterior cingulate lesions result in

A

Abulia ( lack of motivation )

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16
Q

Describe the features of stupor

A

Variable responsiveness
Mute or near mute
Akinesia
Restricted passive movement or catatonic or bizarre posture
Normal reflexes
Responds to visual stimuli
Resists passive eye opening and may blink to pain

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17
Q

What are the three main origins of stupor

A

Structural
Metabolic
Psychogenic

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18
Q

List 4 structural causes of stupor

A

Raised ICP
infection
Dementia
Ictal/ post ictal

19
Q

List 5 metabolic causes of stupor

A 
Hypoglycaemia
Liver/kidney failure
Pituitary /adrenal 
Alcohol
Deficiency states
20
Q

List four psychogenic causes of stupor

A

Depression
Mania
Schizophrenia
Hysteria

21
Q

Depressive stupor presents with

A

Depressive history
Weight loss
Restless motor activity or bizzare postures

22
Q

Treatment for depressive stupor

A

Supportive -fluids
ECT
Antidepressants via NG or IVI
Benzodiazepines

23
Q

How does manic stupor present

A

Lying in ecstasy
Previous mania or affective symptoms
Short episodes of stupor interspersed with over active episodes
Misdiagnosed as attention seeking

24
How does schizophrenic stupor present
Catatonic Lying, sitting or standing Waxy flexibility Interspersed with non directed motor excitement
25
What is the treatment for manic stupor
Treat the mania : Benzos , APs, mood stabilisers, ECT if prolonged Supportive measures
26
What is the treatment for schizophrenic stupor
Supportive Benzos ECT antipsychotics- not very effective and beware malignant hyper pyrexia
27
How does hysterical stupor present?
Sudden dissociations Previous hysteria May co exist with organic illness
28
What is the treatment for hysterical stupor
Supportive Wait Benzos EVT only if prolonged
29
What types of drugs induce stupor
Alcohol Psychotropics Adverse reactions
30
Name four chronic states of altered consciousness
Dementia Hypersomnia Akinetic mutism Apallic syndrome
31
What is locked in syndrome
Conscious- aware of self and the environment No voluntary movement High brain stem pathology with retention of blinking or vertical eye movements via dejerines bundle
32
What is a minimally conscious state
State of severely altered consciousness in which minimal but clearly discernible behavioral evidence of self or environmental awareness is demonstrated Inconsistent but reproducible responses above the level of spontaneous or reflexive behaviors indicating some degree of interaction with surroundings
33
What behaviors are exhibited in MCS
May follow simple commands Gestural or verbal yes/no responses regardless of accuracy Intelligible verbalisation Purposeful or discriminating behavior including movement or affective behaviors that occur contingent in relation to relevant environmental stimuli and are not reflexive
34
People in a minimally conscious state may exhibit .... What addressed
Eye contact or head movement
35
Can people in an MCS hold or use an object
Sometimes yes
36
People in an MCS are emotionless but with .....
Tracking eye movements
37
Describe the features of a persistent vegetative state
``` No awareness of self or environment No sustained behavioral responses No language Cranial nerve function largely intact Roving/ jerky eye movements Sleep wake cycles Stable BP and respiratory drive Incontient ```
38
What are the RCP criteria for diagnosis of PVS
No evidence of awareness of self Cyclical and spontaneous eye movements Extended limbs to pain- no evidence of verbal responsiveness No demonstration of any experience of pain through motor or verbal response Normal respiratory function
39
How should coma patients be examined
History General examination ie skin, temp, BP Neurological examination
40
What are the three components of the GCS
Eye opening Motor Verbal
41
What investigations are done for coma
Lab tests: acidosis, anion gap, osmolar gap- antifreeze Drug screen Blood cultures Imaging EEG CSF
42
What immediate management is available for a coma
``` Oxygenation ABC Correct BP, Temp Glucose Naloxone (opioids), flumenazil (benzo) Correct Na, Ca, and eliminate toxins Neurosurgery and ICP infection ```
43
What long term management should be considered for coma
``` Tracheostomy PEG wean from ventilator Avoid MRSA prevent contractures Protect skin Avoid neurostimulation including drugs ```
44
What factors are associated with poorer prognosis in coma
``` Myoclonic status Absent corneal / pupil at 3 days Absent motor at three days Absent SEP increased serum neurone specific enolase ```
45
How is brain stem death diagnosed
``` Known cause No drugs >36.5c >SPB 100mmHg Eu volaemia, capnia, oxaemia, BP. Absent brain stem reflexes Apnoea with no co2 response when off ventilator ```

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