Coma, Persistent Vegatative State, Brain Death

Question 1

Define coma

Answer 1

A state of unarousable psychological unresponsiveness in which individual shows no response to external stimulus

Question 2

Which classification is used to define when someone is in a coma?

Answer 2

Glasgow coma scale

Question 3

In which GSC rating would someone be considered to be in a coma?

Answer 3

GSC of 8 or less

Question 4

What does consciousness depend on?

Answer 4

Intact ascending reticular activating system
Functioning cerebral cortex

Question 5

What is the reticular activating system responsible for?

Answer 5

Arousal

Question 6

Which part of consciousness are the cerebral hemispheres responsible for?

Answer 6

Awareness of environment

Question 7

What are causes of a reduced conscious level?

Answer 7

Toxic/metabolic states
Seizures
Damage to reticular activating system
Raised ICP

Question 8

List some toxic/metabolic states.

Answer 8

Hypoxia
Sepsis
Hypotension
Drug intoxication
Renal or liver failure
Hypoglycaemia
Ketoacidosis

Question 9

If someone comes in with a low level of consciousness, what will the management be?

Answer 9

ACB approach

(airways, breathing, circulation)

Question 10

Patterns of breathing may give an indication to what is causing the coma. If there is depressed respiration, what could be the cause?

Answer 10

Drug overdose
Metabolic disturbance

Question 11

Patterns of breathing may give an indication to what is causing the coma. If there is increased respiration, what could be the cause?

Answer 11

Hypoxia, hypercapnia, acidosis

Hypercapnia= high levels of CO2 in blood

Question 12

Patterns of breathing may give an indication to what is causing the coma. If there is fluctuating respiration, what could be the cause?

Answer 12

Brainstem lesion

Question 13

In those with reduced conscious level, which condition should be considered and treated on suspicion?

Answer 13

Meningitis

Question 14

Upon examination, if a patient has no meningism or focal brainstem/lateralising cerebral signs, what could be the cause of their coma?

Answer 14

Toxic cause
Metabolic cause
Systemic cause

Question 15

Upon examination, if a patient has meningism but no focal brainstem/lateralising cerebral signs, what could be the cause of their coma?

Answer 15

Meningitis
Encephalitis
Subarachnoid haemorrhage

Question 16

Upon examination, if a patient focal brainstem/lateralising cerebral signs and possibly meningtism, what could be the cause of their coma?

Answer 16

Focal cerebral issue e.g. tumour or infarct

Question 17

If there are no focal signs or meningism, which investigations may be done to try and work out the toxic/metabolic/systemic cause of the coma?

Answer 17

Toxicology screen, including alcohol levels
Blood sugar and electrolytes
Asses hepatic and renal function
BP
Acid-base assessment and blood gas
Consider carbon monoxide poisoning

Question 18

If there is someone in a coma without focal or lateralising signs but with meningism, which investigations may be done to make a diagnosis?

Answer 18

CT head
Lumbar puncture

-> as remember, with these symptoms, likely to be subarachnoid haemorrhage, meningitis or encephalitis

Question 19

In those with focal brainstem or lateralising signs, you’d be more worried of cerebral tumour, haemorrhage, infarction or abscess. Therefore, which investigations would be done?

Answer 19

CT or MRI

Question 20

What is ‘locked in’ syndrome?

Answer 20

Patient has total paralysis below level of third nerve nuclei.

Question 21

What is observed in ‘locked in’ syndrome?

Answer 21

Patient is able to open, elevate and depress eyes and has no horizontal or voluntary eye movement

Question 22

What care would be involved in looking after a patient in a coma?

Answer 22

Maintenance of vital functions
Care of skin and avoidance of pressure sores by moving patient
Attention to bowel and bladder function
Control of seizures
Prophylaxis of DVT, peptic ulceration

Question 23

Which two things are those who re bed bound at higher risk of developing?

Answer 23

DVT
Peptic ulceration

Question 24

In non-epileptic attacks, a patient can seem like their in a coma even though they are not.
In who are non-epileptic attacks are more likely to happen?

Answer 24

Young
Female more than male
Psychiatric history

Question 25

List the clinical features of a non-epileptic attack.

Answer 25

Sinusoidal tremor
Pelvic thrusting
Side to side head movements
Eyes closed and resists opening
Partial responsiveness

Question 26

Which scale can be used to clinically predict whether someone is having a stroke or not?

Answer 26

Rosier scale

-> scale >0 predicts stroke

Question 27

What is hemicraniectomy and when is it used?

Answer 27

Decompressive surgery for severe cerebral swelling post-stroke