Coma

Question 1

Define coma

Answer 1

A state of unrousable psychological unresponsiveness in which the subjects lie with eyes closed and show no psychologically understandable response to external stimulus or inner need

Question 2

What does consciousness depend on?

Answer 2

An intact ascending reticular activating system (arousal)

A functioning cerebral cortex of both hemispheres (environmental awareness)

Question 3

What are some causes of decreased GCS?

Answer 3

Seizures 
Damage to reticular activating system 
Causes of raised ICP 
Drug intoxication 
Liver/renal failure 
Sepsis/ hypoxia/ hypercapnia, hypotension 
Hypoglycaemia, ketoacidosis

Question 4

Define persistent vegetative state?

Answer 4

A state in which the brainstem recovers to an extent but there is no evidence of recovery cortical function. Arousal and wakefulness but no regain or purposeful behaviour

Question 5

What is locked in syndrome?

Answer 5

Total paralysis below level of third nerve nuclei. Can open, elevate, depress eyes but no horizontal movement and no voluntary eye movements

Question 6

What are the causes of depressed respiration?

Answer 6

Drug overdose

Metabolic disturbance

Question 7

What are the causes of increased respiration?

Answer 7

Hypoxia
Hypercapnia
Acidosis

Question 8

What is a cause of fluctuating respiration?

Answer 8

Brainstem lesion

Question 9

What must be done during resuscitation?

Answer 9

Airway
Breathing 
Circulation 
Blood samples 
Establish baseline BP, pulse, temp, IV access, stabilise neck 
Examine for meningitis

Question 10

What should be monitored during a coma?

Answer 10

Temperature 
Heart rate, BP, CVS 
Respiration 
Skin, breath 
Abdomen 
Meningism 
Fundal examination

Question 11

What is the neurological assessment of coma?

Answer 11

Glasgow coma scale
Brainstem function
Motor function and reflexes

Question 12

What are some causes of coma without focal or lateralising signs and without meningism?

Answer 12

Epilepsy 
Intoxications 
Hyper/hypothermia 
Systemic infections
Metabolic disturbances 
Anoxic/ ischaemic conditions

Question 13

What investigations should be used coma without focal or laterlising signs and without meningism?

Answer 13

Toxicology screen incl alcohol level 
Measure blood sugar and electrolytes 
Acid-base hepatic and renal function 
Measure blood pressure 
Consider carbon monoxide poisoning

Question 14

What are the causes for a coma without focal or lateralising but with meningsm?

Answer 14

Subarachnoid haemorrhage
Meningitis
Encephalitis

Question 15

What are the investigations for a coma without focal or lateralising but with meningsm?

Answer 15

CT head scan

Lumbar puncture

Question 16

What are the causes of coma with focal brainstem or laterlising cerebral signs?

Answer 16

Cerebral tumour
Cerebral haemorrhage
Cerebral infarction
Cerebral abscess

Question 17

What are the investigations for a coma with focal brainstem or lateralising cerebral signs?

Answer 17

CT or MRI obligatory
Metabolic screens
Lumbar puncture
EEG

Question 18

What are the medical causes of coma lasting more than 5 hours?

Answer 18

Drug ingestion +/- alcohol
Hypoxia
Haemorrhage/infarction
Metabolic

Question 19

What factors can affect the prediction of outcome in coma?

Answer 19

Age

Cause, depth and duration of coma

Question 20

What should be done to continue care for patients in coma?

Answer 20

Vital functions maintenance 
Skincare (avoid pressure sores) 
Bladder and bowel function attention 
Control of seizures 
Prophylaxis of DVT, peptic ulceration 
Prevention of contractures

Question 21

How should a head injury be managed?

Answer 21

Stabilise cervical spine 
Airway/breathing/circulation 
Intubation/ventilation if GCS <8 
Treat raised ICP 
Cranial imaging

Question 22

What are the treatment options for raised ICP?

Answer 22

Surgery to relieve pressure 
Osmotic agents (Mannitol)
Reduce pain 
Maintain good PO2, reduce PCO2
Reduce metabolism 
Nurse with head at 30-45% (venous return)