Coma, Cohen

Question 1

most common causes of comas

Answer 1

cardiac pulmonary failure
drug alcohol overdose
severe derangements of oran function with abnormal serum chemistries of pH: hypoglycemis, renal failure etc
stroke or hemorrhage
cranial truma
infections
psychiatric pseudo coma or catatonia

Question 2

how long for cardiac or pulm failure before in coma

Answer 2

5 minutes

hypoxic ischemic damage throughout brain

Question 3

important part about addressing a comatose patient

Answer 3

learning the history

chornic conditions, drug use, psych disorder etc

Question 4

what aspect of coma is important to Dx and prognosis

Answer 4

duration of coma

Question 5

Immediate steps for comatose patient

Answer 5

stabilize ABC
BP perfusion check
peripheral or central IV line
intubation/ventilation if needed
look for evidence of trauma
Hx from witnesses, family etc
comprehensive labs like CBC and toxicology
check if any chance opiate overdose(give naloxone)

Question 6

Decerebrate

Answer 6

arm and leg in extension

brainstem or thalamus injury

Question 7

decorticate

Answer 7

arms flex legs extended

widespread damage to both hemispheres

Question 8

posturings

Answer 8

posture of coma patient that indicates serious disorder

Question 9

general neuro exam of comatose patient

Answer 9

observe:
spontaneous respiration or ventilator dependent
spontaneous movement, unilateral etc
abnormal movements like tremors or jerks
response to voice, physical stimulation or none
general appearance

Question 10

Brainstem functions to check on comatose patient

Answer 10

pupillary light reaction
pupillary diameters
corneal reaction
eye movements
oculocephalic reflex
oculovestivular reflex
gag

Question 11

pupillary light reaction

Answer 11

CN II and III

Question 12

pupillary diameters

Answer 12

II III

Question 13

corneal reacion

Answer 13

CN V VII

Question 14

CN eyemovements

Answer 14

III IV VI

Question 15

what is oculocephalic reflex

Answer 15

dolls eyes

eyes in opp direction of head turn if no inhibition of hemispheres

Question 16

oculovestibular reflex

Answer 16

cold calorics
eyes deviate conjugately toward ear given ice water, nystagmus away
pons and medulla
or eye deviate away or ear with warm water nystagmus towards

Question 17

first reflex usually to be lost

Answer 17

gag

Question 18

last reflex to be lost

Answer 18

pupillary light reaction

Question 19

Where are nuclei for CN III

Answer 19

top of brainstem in midbrain

Question 20

what can compress CN III nuclei

Answer 20

if there is uncal herniation of ipsilateral and sometimes contralateral

Question 21

what will it look like with compromise to nuclei of CN III

Answer 21

dilated unreactive pupil

can still move eye lateral

Question 22

most important signs for prognostic indicator for comatose patient

Answer 22

pupillary reaction to light

spontaneous movements

Question 23

what patients are exempt from 5% living after coma for 72 hours

Answer 23

trauma swelling, sedation from drug overdose, hypothermia, multiple missing brain stem reflexes

Question 24

brain dead means what

Answer 24

legally dead

Question 25

requirements for brain death

Answer 25

no evidence cerebral function
no response to stimulation
no movements
no vocalization
no evidence brainstem function

Question 26

how to confirm loss of brainstem function

Answer 26

apnea test
ventilator turned off but 100% O2 still given
if CO2 rises to 60mmHg and there is no respiratory effort = brain dead

Question 27

when to tell family about coma

Answer 27

right away

no matter what before 72 hours

Question 28

families relieved to learn what of comatose patients

Answer 28

no pain or suffering

Question 29

Tx brain death patients

Answer 29

no further Tx. Kept until organs can be taken if donator

Question 30

Vegetative state

Answer 30

loss of cerebral hemispheres but maintenance of part or all of brainstem

Question 31

vision in vegetative state

Answer 31

have gross vision but no specific response to what patient “sees”

Question 32

Criteria for persistent vegetative state

Answer 32

>1 mo vegetative state
no awareness self surroundings
no meaningful communication
facial expressions not accurate to stimulation
sleep wake cycles can be intact
arm or leg movements but no voluntary control
CV function maintained
incontinent bowle and bladder

Question 33

prognosis vegetative state

Answer 33

hopelessafter 1 mo

by 3 mo definitely hopeless