Coma

Question 1

delirium

Answer 1

– fluctuating confusion, inattention, misperceptions (illusions or hallucinations).

Question 2

stupor

Answer 2

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

Question 3

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

GCS

Answer 4

Motor
Obeys – 6
Localizes – 5
Normal flexion/withdraws– 4
Abnormal flexion (decort)– 3
Extension (decerebrate) – 2
No response – 1

Verbalization
Orientated – 5
Confused – 4
Inappropriate words – 3
Incomprehensible sounds – 2
No response – 1

Eye opening
   Spontaneously – 4
   To voice – 3
   To pain – 2
   No response – 1

Question 5

decorticate

Answer 5

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

Question 6

decerebrate

Answer 6

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

Decerebrate is worse than decorticate

Question 7

severity of TBI

Answer 7

Mild = GCS 15-13
Moderate = 12-9
Severe = 8-3

Question 8

GCS definition of coma

Answer 8

Patients are in coma if they are unable to:

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

(100% if GCS 3-7, 0% if 9-12, 50% if 8)

Question 9

What happens after coma?

Answer 9

Death (about 50 % of trauma patients at 1 month),
Revival of consciousness, or
Vegetative state (VS), where sleep-wake cycles re-establish, but there is no sign of cognitive function.
Minimally conscious state (MCS)

Question 10

determination of death

Answer 10

An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brainstem, is dead.
A determination of death must be made in accordance with accepted medical standards.

Question 11

first criterion of brain death

Answer 11

“Unresponsiveness”

The patient is in deep coma. The GCS is 3.

Question 12

second criterion of brain death

Answer 12

“Cerebrally modulated motor responses are absent during application of painful stimulus.”

(Spinal reflexes may be present. Seizures or flexion/extension posturing may not)

Question 13

third criterion

Answer 13

“Brainstem reflexes are absent”

pupils, corneals, oculocephalic, oculovestibular, cough, gag, respirations

Question 14

determination of brain death (ALL)

Answer 14

Core body temp of 32.2 C (90 F)
Toxicology tests find no explanation for low neurological state (CNS suppressing medications may be subtherapeutic)
Adequate BP and pulse (SBP 90, P >50)
No voluntary movements or response to pain (spinal reflexes are OK, e.g., DTR,. Babinski)

absence of :
Pupillary light reflex
Corneal reflex
Oculocephalic reflex (doll’s eyes)
Oculovestibular reflex (cold calorics)
Cough reflex
Gag reflex
Respiratory effort (apnea test)

Question 15

corneal reflex

Answer 15

Touch cornea with tissue. (CNs V and VII)

There must be no blink response in either eye.

Question 16

Oculovestibular reflex (cold caloric test)

Answer 16

Flush each external auditory canal with 20 ml ice water x 2 and observe (CNs VIII, III, IV and VI)

There must be no eye movements

Question 17

cough reflex

Answer 17

Suction the trachea at the carina. (CN X)

There must be no cough response.

Question 18

gag reflex

Answer 18

Touch the oropharynx with Q-tip. (CNs IX and X)

There must be no movement of the oral structures.

Question 19

Apnea test procedure

Answer 19

(before discontinuing the ventilator)

1. 100% oxygen delivered for 10 minutes
2. pCO2 around 40 mmHg on arterial blood gas
3. Maintain adequate blood pressure and pulse
4. Determine if pt has “tripped the vent” recently
5. Disconnect vent from ET tube (begin timing)
6. Deliver oxygen at 6 L/min by t-piece
7. Observe and feel for respiratory effort (if breathing is observed, stop test/connect vent)
8. After 8 minutes, draw blood gas and reconnect ventilator. If no respiratory effort was observed and the pCO2 is 20 or more mmHg higher than baseline, the apnea test is POSITIVE (c/w brain death)

Question 20

When are confirmatory tests performed?

Answer 20

• BP or pulse cannot be stabilized
• Anatomy does not allow examination
• Patient is a young child (always if

Question 21

vegetative state

Answer 21

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

(Unconscious without awareness but with wakefulness and the appearance of sleep-wake cycles )

thalamus plays a role

When due to trauma, it is considered to be permanent (

Question 22

minimally conscious state

Answer 22

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.