Coma

Question 1

A patient arrives at A+E unconscious. What biochemical test do you want to do immediately?

Answer 1

Blood glucose

Hypoglycaemia can cause coma

Question 2

Describe the GCS system?

Answer 2

Eye opening

4: spontaneously
3: to voice
2: to pain
1: none

Verbal

5: orientated to TPP
4: confused
3: inappropriate words
2: incomprehensible sounds
1: none

Motor:

6: obeys commands
5: localises to pain
4: flexes to pain
3: abnormal flexion to pain
2: extension to pain
1: none

Question 3

What is meant by decerebrate and decorticate motor response?

Answer 3

Decorticate: another word for abnormal flexion response to pain (M3 on GCS)

Decerebrate: another word for extension response to pain (M2)

Question 4

Methods of applying painful stimulus?

Answer 4

Supraorbital pressure
Mandibular pressure (jaw thrust)
Trapezius squeeze
Nailbed pressure
Sternal rub

Question 5

Differential diagnosis of coma?

Answer 5

VITAMIN D

V: stroke, SAH

I: meningitis, encephalitis, toxoplasmosis

T: Sub-dural, extra-dural, blood loss, hypoxic brain injury

A

M: hypoglycaemia, dehydration, DKA, electrolyte imbalance

I: drugs, alcohol, delerium

N: SOL

D

Question 6

A patient arrives at A+E unconscious. What investigations will you do?

Answer 6

CT head
Urine toxicology
ECG
CXR

Bloods: FBC, U+E, glucose, clotting, plasma paracetamol and salicylate

Blood cultures

ABG

Question 7

A patient arrives at A+E unconscious. He has pinpoint pupils and his respirations are shallow. What do you think is the cause of his coma?

Answer 7

Opiate overdose

Question 8

What are the symptoms of an opiate overdose?

Answer 8

Decreased level of consciousness

Pinpoint pupils

Respiratory depression

Also might see needle marks indicating IVDU

Question 9

Why does SAH cause coma?

Answer 9

Blood in CSF space, ventricles

Raised ICP

Question 10

Why do brain injuries and things like SAH cause fixed dilated pupil?

Answer 10

Compression of parasympathetic part of III nerve, which controls pupil constriction

Parasympathetic nerves are carried around edge of nerve

Question 11

Management of SAH?

Answer 11

ABCDE
Urgent CT head
Admit to neuro ITU

IV Mannitol

Nimodipine to prevent vasospasm

Interventional radiology: coiling, clipping

Question 12

Features of brainstem death?

Answer 12

1. Fixed dilated unresponsive pupils
2. No corneal reflex
3. Absent oculovestibular reflex (cold water in ear )
4. No response to supraorbital pressure
5. No cough or gag reflex
6. No observed respiratory effort in response to disconnecting ventilator