Coma - Cohen Flashcards
MC cause of coma
cardiac or pulmonary failure for over 5 minutes
hypoxic-ischemic damage to brain
also - drug and alcohol overdose - in ER
renal and hepatic failure
toxins to brain > coma
best way to limit damage in coma
learn cause
talk to witness**
- medical conditions?
- history of trauma?
duration of coma
important in diagnosis and prognosis of coma
immediate steps in coma patient
stabilize - ABCs BP and perfusion check IV line - draw blood and give dextrose and thiamine** intubate/ventilate take history
opiate overdose
give naloxone (narcan)
myoclonic jerks
cerebral hemisphere damage
brainstem function
CN function
oculocephalic reflex
cold calorics
eye deviate to ice water
away from hot water
bad sign**
involve pons and medulla
pupil rxn
CN II and III
corneal reaction
CN V and VII
eye movement
CN III, IV, VI
gag reflex
pons and medulla
CN III nuclei
top of brain stem
- compressed uncal herniation
- see dilated pupil that can only move laterally
prognostic indicators of coma
pupillary rxn to light
spontaneous movement
patient coma 72 hours
<5% chance of meaningful recovery
-unless hypothermic, drug OD, reversible swelling from trauma
brain death
no function of brain stem
cardiac function - pulses
but no respirations or brain fxn
cardiac function only last week or less
legally dead
brain dead
medical care stops - except organ removal
requirements for brain death
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
apnea test
100% O2 - PCO2 to 60mmHg
- should stimulate respirations
- if not = brain dead
family
need to tell them
-important they know - pt no pain or suffering
also - tell family no drugs on board
vegetative state
only brain stem function
no cerebral hemisphere fxn
grunts or laughter, sleep-wake cycles, respiration, HR, swallow, eye movements, facial contraction
criteria for persistent vegetative state
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
brain death
physician decision
ending vegetative state
family decision
terri schiavo
bulimic - severe hypoK - in vegetative state
- for years - never improved
- laws passed - outlaw termination of care
