Coma

Question 1

Define delirium

Answer 1

Fluctuating levels of consciousness with confusion, inattention and misperceptions such as illusions or hallucinations

Question 2

Define stupor

Answer 2

A sleep like state from which the patient can be aroused, but 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 and is a Glasgow Coma Scale score of 8 or less

Question 4

Define decerebrate posturing

Answer 4

An involuntary flexion of the arms with lower body extension which indicates brain damage at the level of the diencephalon or cerebral hemispheres

Question 5

Define decorticate posturing

Answer 5

An involuntary extension of the arms and lower extremities which is suggestive of a lesion at the brainstem. This prognosis is worse for this than decorticate posturing

Question 6

Discuss the criteria for establishing brain death

Answer 6

1. Unresponsiveness
2. Cerebrally modulated motor responses are absent during application of painful stimulus
3. Brainstem reflexes are absent

Also: Core body temp of 32.2C, Toxicology tests find no explanation for low neurological state, Adequate BP, and other low brain activity states that are NOT coma or brain death

Question 7

Discuss ethical, legal, and cultural issues related to brain death and organ transplantation

Answer 7

Two methods of donation:

1. Donation after brain death
2. Donation after cardiac death

Both require a declaration of death prior to organ harvesting and the surgical team harvesting the organs may not be involved with the determination of death.

In CO, if the patient lacks advance directives, there is no automatic proxy. All the interested persons must be contacted by the physician and the interested persons must choose a proxy by consensus. If there is no consensus or no interested persons, then there must be a petition to the court for a guardian

Question 8

Describe the anatomical pathways tested with: the corneal blink reflex

Answer 8

CNs V and VII. Use cotton wisp or dull object to touch cornea. There cannot be a blink from either eye.

Question 9

Describe the anatomical pathways tested with: cold water calorics

Answer 9

CNs VIII, III, IV and VI. Can be done by “doll’s eyes” method: rotating head and watching for eye movements. In coma, eyes may lag, but will return to midline. In brain death, there are no movements of any kind. Can also be done by flushing external auditory canal with 20mls of ice water and observe eyes. In coma, eyes will move away from cold water but in brain death eyes will not move.

Question 10

Describe the anatomical pathways tested with: the cough reflexes.

Answer 10

Testing CN X. Test by suction of the carina of the trachea. Looking for a cough or a bucking against the ventilator. Indicates patients initiated breath. No cough reflex in brain death.

Question 11

Describe the anatomical pathways tested with: the gag reflexes.

Answer 11

CNs IX and X. Touch the oropharynx on each side with swab or Q-tip, look for movement of the oral structures. In brain death, there is no motor effect

Question 12

Whats a vegetative state?

Answer 12

Eyes open spontaneously; sleep-wake cycles resume but there is no evidence for perception, communication or purposeful motor activity. These states are associated with problems of the thalamus and the intralaminar nuclei within the thalamus. When due to trauma, vegetative state is considered permanent after 12 months. When due to anoxia, vegetative state is considered permanent after 3 months.