Coma and Consicousness

Question 1

What are five of the more common causes of comas?

Answer 1

1. Herniation syndrome and trauma
2. Structural / brainstem lesions
3. Metabolic
4. Toxic syndromes
5. Infections

Question 2

What kind of posturing is typically observed with pontine strokes?

What is damaged in a Pontine Stroke?

Answer 2

DECEREBRATE POSTURING

Arms and legs straight out
Toes pointed downward
Head and neck arched backwards
Muscles tightened w/ rigidity

GCS 2 in motor

Brainstem damage or compression of midbrain, lesion of cerebellum

Question 3

If you have a comatose PT that you suspect is metabolic in origin; what could some of the potential causes be?

Answer 3

HYPOglycemia, HYPERglycemia
HYPOthyroid
HYPOcalcemia,
HYPOnatremia

HYPERammonemia
HYPERkalemia

Anemia or Uremia
Status epilepticus
Anoxia/Hypoxia (MOST COMMON)

Thiamine deficiency

Question 4

What are some of the clinical features of a PT presenting with a metabolic coma?

Answer 4

Symmetric pupils with constriction
Muscle tone decreased
Tremor, asterixis, multifocal myoclonus
(cortical suppression and ARAS disruption)

Question 5

What are the scores associated with Eye Opening in the GCS?

Answer 5

Spontaneous: 4
Respond to verbal command: 3
Response to pain: 2
No eye opening: 1

Question 6

What are the scores associated with Best Verbal Response in the GCS?

Answer 6

Oriented:  5
Confused:  4
Inappropriate words:  3
Incomprehensible words:  2
No verbal response:  1

Question 7

What are the scores associated the Best Motor Response in the GCS?

Answer 7

Obeys commands:  6
Localizing response to pain:  5
Withdrawal response to pain:  4
Flexion to pain:   3
Extension to pain:  2
No motor response:   1

Question 8

Using the FOUR Score criteria, a score lower than what would indicate expected death of the PT?

What are the major components of the FOUR Score criteria?

Answer 8

<6

Respiratory
Brainstem reflexes
Motor Response
Eye Response

Question 9

What studies should you consider ordering for your PT as you are attempting to determine the underlying cause of their comatose state?

Answer 9

If nuchal rigidity is present (LUMBAR PUNCTURE to R/O meningitis)

EKG
CT (used to rule out large CVA, hemorrhage, or tumor)
EEG

LABS
TSH
CBC w. diff
CMP
Abg
NH3
Blood culture

Question 10

PT presents with ataxic breathing pattern and pin-point but reactive pupils… The coma has come on acutely and you suspect….

Answer 10

Pontine Hemorrhage. (also presents with decerebrate posturing or flaccidity)

Question 11

PT presents with status epilepticus and the appropriate prescription therapy should include what?

Answer 11

IV Lorazepam
~~~followed by~~~
IV Dilantin or Valproic Acid

(Use IV phenobarbital if ineffective)