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Neuro > COMA + Assessing Obtunded Patient > Flashcards

COMA + Assessing Obtunded Patient Flashcards

1
Q

What is a coma

A

GCS <8

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2
Q

What is GCS score made up of

A

Eye opening /4
Verbal response / 5
Motor response / 6

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3
Q

How is eye opening graded

A

4 - spontaneous
3 - speech
2 - pain
1 - no response

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4
Q

How is verbal response graded

A 
5 - orientated
4 - confused 
3 - inappropriate words
2 - sounds
1 - no response
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5
Q

How is motor response graded

A

6 - obeys commands (e.g. stick out tongue)

Apply supra-orbital pressure
5 - localised to pain - hand above clavicle
4 - flexion withdraws (normal) - above and away from body / stimulus
3 - abnormal flexion (decorticate) - corticospinal - elbow bends and hand comes across body
2 - abnormal extension (decerebrate) - brain stem typically pontine or herniation - elbow starts to extend backwards
1 - no response

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6
Q

What are causes of decreased GCS

A 
Metabolic 
Toxins
Trauma
Ischaemic 
Infection
Systemic 
Raised ICP 
Damage to reticular activating system 
Seizures
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7
Q

What are metabolic / toxic causes

A 
Hypoxia
Hypothermia 
Sepsis
Drugs
Renal / liver failure
Hypoglycaemia
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8
Q

What are toxic causes

A

Drugs

CO poisoning

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9
Q

What would cause no focal or menngism signs

A 
Ischaemia
Metabolic
Infection
Systemic
Epilepsy
Hypothermia
Toxins
Trauma
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10
Q

What would cause menngism

A

Menignitis

SAH

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11
Q

What would cause focal

A

Tumour
Haemorrhage
Abscess
Infarction

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12
Q

How do you initially manage coma

A 
Resus
ABCDE
Stabilise neck
Examination
Send bloods
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13
Q

When would breathing be depressed

A

Drug - opiates

Metabolic

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14
Q

When would breathing be increased

A

Hypoxia

Acidosis

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15
Q

What would cause fluctuating breathing

A

Brain stem

Raised ICP

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16
Q

What else do you examine

A

GCS
Brain stem function
Motor function and reflexes

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17
Q

What do you do if no focal or meningitis signs

A 
Tox screen
Blood sugar
Hepatic and renal function
BP 
Blood gas
CO poison
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18
Q

What if no focal but meningitic signs

A

CT

LP

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19
Q

What do you do if focal signs

A

CT / MRI

LP

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20
Q

What tests brain stem function

A 
Pupils
Corneal response
Eye movement
Oculocephalic reflex
Oculovestibular reflex
Resp pattern
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21
Q

What is oculocephalic response

A

Eyes move with head tilt

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22
Q

What is oculovestibular response

A

Nystagmus

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23
Q

What CN is pupil response checking

A

2+3

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24
Q

Corneal response

A

5+7

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25
Q

Eye movements

A

3,4,6

26
Q

Eye reflexes

A

3,4,6,8

27
Q

Resp patterm

A

Medulla

28
Q

What affects outcome

A

Age
Cause
Duration
Brain stem reflexes

29
Q

What is change of recovery in traumatic coma >6 hours

A

15%

30
Q

What is Locked in

A

Damage to front of pons where spinothalamic tract passes
Causes total paralysis below 3rd CN
Can only open and depress eyes and breath
No other movement

31
Q

How do you treat coma

A 
Maintain vital functions
Skin care
Bladder + bowel 
Control seizures
DVT prophylaxis
Prevent contractures
Consider locked in
32
Q

If pupils bilateral dilated what does this suggest

A

Cerebral herniation crushing optic nerve as bilateral defect
Irreversible
Unopposed dilator pupillae

33
Q

What does unilateral dilated pupil suggest

A

Problem with oculomotor nerve (III)

34
Q

What is important to know when assessing obtunted patient

A 
Lobe of brain affected
Is cerebellum affected
Are CN affected 
Is there spinal cord damage
Is there peripheral nerve damage
35
Q

What do you want to know about spinal cord damage

A

What level
Myelopathy
Radiculopathy

36
Q

What is frontal lobe responsible for

A 
Voluntary control of movement
Speech - BROCA's 
Saddaic eye movement
Bladder control
Memory 
Gait
37
Q

What does SMA do

A

Higher order functions such as initiative / apathy / motivation
Civil and approropiate behaviour

38
Q

What does prefrontal cortex do

A 
Integrates sensory info 
Generate response to environmental changes 
Select most appropriate response 
Maintain set task
Order data etc
39
Q

What can you do if frontal cortex in tact

A

Make appointments
Give coherent Hx
Spell words backward
Say as many words beginning with letter

40
Q

What is parietal lobe responsible for

A 
Primary sensory centre
Body image representation
Awareness of body 
Visualspatial coordination
Language
Numeracy
41
Q

What is superior lobe used for

A

Awareness of contralateral half of body

SAA

42
Q

What is inferior lobe for

A

Visual

Auditory

43
Q

What is cortical sensory syndrome

A

Sensory inattention
Agnosia
Asteroagnosia
Two point discrimination

44
Q

If damage on dominant side of parietal lobe

A

Dyscalcui
L/R disorientation
Agrpahia
Finger anomia

45
Q

If on non-dominant side

A

Hemi-neglect
Apraxia
Ideomotor apraxia
Loss of spatial awareness

46
Q

What is temporal lobe response for

A 
Bilateral process of auditory input 
LANGUAGE 
Wernicke's - understanding
Long term memory
Emotion 
Perception of moving objects / recognising phases
47
Q

What is responsible for long term memory

A

Hippocampus

48
Q

What is responsible for emotion

A

Amygdala

49
Q

What is occipital lobe responsible for

A

Visual field

50
Q

Where does optic radiation travel through

A

Parietal and occipital lobe

51
Q

What does cerebellar damage cause

A 
Dysdisdochokinesia
Ataxia
Nystagmus
Inattention tremor
Slurred speech - baby hippocampus / scanning dysarthria
Hypotonia
Past pointing
52
Q

How do you test

A

Finger nose test
Knee heel test
Walk in straight line

53
Q

When do test for brain death

A

If in deep coma with known aetiology
Reversbile causes excluded
No sedation
Normal electrolyte levels

54
Q

Who can test

A 
2+ doctors 
5+ post grad expereince
At least one consultant
Must not be a member of transplant team
Must test 5 hours apart
55
Q

What is done to test for brain death

A 
Fixed dilated pupils
No corneal reflex
No oculovestibular reflex
No response to suborbital pressure
No cough reflex to bronchial stimulation
No gag reflex to pharyngeal stimulation
No resp effort when ventilator off >5 mins to allow pCO2 to rise >6
56
Q

What is brainstem responsible for

A 
10/12 cranial nerve 
Major eye movement
Breathing
HR
Swallowing
Consciousness
57
Q

What motor if brain stem damaged

A

Contralateral hemiparesis due to tracts crossing over

58
Q

When do you intubate

A

GCS <8

59
Q

Quick test for CSF

A

Glucose
CSF contains
Mucous does not

60
Q

Decorticate posturing

A

Due to lesion above the red nucleus

61
Q

Decerebrate

A

Lesion below red nucleus

Usually brain stem / pontine stroke

Neuro (19 decks)

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