coma

Question 1

GCS what are assessed

Answer 1

eye opening, motor response, verbal response

Question 2

what are the scorings on GCS eye opening

Answer 2

spontaneous (4), to speech (3), to pain (2), no response (1)

Question 3

what are the scorings on GCS motor response

Answer 3

obeys (6), localises to pain (5), withdraws to pain (4), flexion to pain (3), extension to pain (2), no response to pain (1)

Question 4

what are the scorings on GCS verbal response

Answer 4

orientated (5), confused (4), inappropriate speech (3), incomprehensible sounds (2), none (1)

Question 5

what is conciousness dependent on

Answer 5

ascending reticular activating system (RAS), cerebral cortex

Question 6

what is coma

Answer 6

state of unrousable unresponsiveness

Question 7

what are the four mechanisms of coma

Answer 7

brainstem lesion, brainstem compression, diffuse brain dysfunction, massive cortical damage

Question 8

example of brainstem lesion causing coma

Answer 8

stroke, haemorrhage, infarction, demyelination, neoplasm

Question 9

examples of brainstem compression causing coma

Answer 9

brain tumour, cerebellar mass, haematoma, abscess

Question 10

examples of diffuse brain dysfunction causing coma

Answer 10

drug overdose, CO poisoning, resp failure with CO2 retention, metabolic- Na,Ca, glucose, trauma, severe uraemia, hepatic encephalopahty, meningitis, encephalitis, seizures

Question 11

does a single focal hemisphere lesion cause a coma

Answer 11

no, only if it is compressing the brainstem

Question 12

what is damaged in persistent vegetative state

Answer 12

cortex and hemispheres. brainstem and ARAS intact so breathing is normal

Question 13

what is persistent vegetative state

Answer 13

no awareness or response to stimuli. appears awake as opens eye and sleep-wake cycle. permanent when over 12m no recovery following trauma or 6m other causes

Question 14

what is damaged in locked in syndrome

Answer 14

ventral pons (within the brainstem). intact ARAS and cortex

Question 15

what is minimally conscious state

Answer 15

some limited awareness.may emerge from vegetative to this

Question 16

what is brainstem death

Answer 16

all brainstem reflexes are absent. oculocephalic reflex- when move head, eyes follow so stationary relative to orbit; pupils fixed and unresponsive, absent corneal reflexes, no vestibular ocular reflex, no motor response cranial nerves, no cough/gag. spontaneous respiration absent

Question 17

what is Cheyne Stokes resp pattern

Answer 17

fluctuating hyperpnoea and apnoea indicating bilateral cerebral or upper brainstem

Question 18

what is Kussmauls breathing

Answer 18

deep sighing hyperventilation- DKA and uraemia

Question 19

what are lateralising signs used for

Answer 19

coma makes it difficult to recognise lateralising signs so a specific few are used

Question 20

what lateralising signs are used in coma

Answer 20

asymmetry of response to visual threat, face, tone (hemiparesis), posturing, response to painful stimuli, tendon reflexes

Question 21

what investigations can be done in coma

Answer 21

blood and urine- drugs; biochem, metabolic and endocrine, ABG, check for porphyria or malaria

Question 22

what brain imaging can be used

Answer 22

CT is best although might not pick up early infarcts