Coma - Cohen

Question 1

MC cause of coma

Answer 1

cardiac or pulmonary failure for over 5 minutes

hypoxic-ischemic damage to brain

also - drug and alcohol overdose - in ER

Question 2

renal and hepatic failure

Answer 2

toxins to brain > coma

Question 3

best way to limit damage in coma

Answer 3

learn cause

talk to witness**

• medical conditions?
• history of trauma?

Question 4

duration of coma

Answer 4

important in diagnosis and prognosis of coma

Question 5

immediate steps in coma patient

Answer 5

stabilize - ABCs
BP and perfusion check
IV line - draw blood and give dextrose and thiamine**
intubate/ventilate
take history

Question 6

opiate overdose

Answer 6

give naloxone (narcan)

Question 7

myoclonic jerks

Answer 7

cerebral hemisphere damage

Question 8

brainstem function

Answer 8

CN function

Question 9

oculocephalic reflex

Answer 9

cold calorics

eye deviate to ice water
away from hot water

bad sign**

involve pons and medulla

Question 10

pupil rxn

Answer 10

CN II and III

Question 11

corneal reaction

Answer 11

CN V and VII

Question 12

eye movement

Answer 12

CN III, IV, VI

Question 13

gag reflex

Answer 13

pons and medulla

Question 14

CN III nuclei

Answer 14

top of brain stem

• compressed uncal herniation
• see dilated pupil that can only move laterally

Question 15

prognostic indicators of coma

Answer 15

pupillary rxn to light

spontaneous movement

Question 16

patient coma 72 hours

Answer 16

<5% chance of meaningful recovery

-unless hypothermic, drug OD, reversible swelling from trauma

Question 17

brain death

Answer 17

no function of brain stem

cardiac function - pulses

but no respirations or brain fxn

cardiac function only last week or less

Question 18

legally dead

Answer 18

brain dead

medical care stops - except organ removal

Question 19

requirements for brain death

Answer 19

not hypothermic, drug OD, or swelling from trauma

no evidence of cerebral fxn
no evidence brainstem fxn - reflexes absent
-no spontaneous respirations

confirmed apnea test - ventilator turned off, 100% O2 delivered until pCO2 to 60mmHg - this should stimulate respirations

Question 20

apnea test

Answer 20

100% O2 - PCO2 to 60mmHg

• should stimulate respirations
• if not = brain dead

Question 21

family

Answer 21

need to tell them
-important they know - pt no pain or suffering

also - tell family no drugs on board

Question 22

vegetative state

Answer 22

only brain stem function

no cerebral hemisphere fxn

grunts or laughter, sleep-wake cycles, respiration, HR, swallow, eye movements, facial contraction

Question 23

criteria for persistent vegetative state

Answer 23

one month veg state

no awareness of self - eye movements do occur
no communication
arm or leg movements no directed purpose
inconinent

hopeless by 3 months

Question 24

brain death

Answer 24

physician decision

Question 25

ending vegetative state

Answer 25

family decision

Question 26

terri schiavo

Answer 26

bulimic - severe hypoK - in vegetative state

• for years - never improved
• laws passed - outlaw termination of care