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MBChB - Y2 - Systems - Nervous System > Coma, Persistent Vegetative State, Brain Death > Flashcards

Coma, Persistent Vegetative State, Brain Death Flashcards

1
Q

What are the features of bells palsy?

A

Whole half of the face is paralysed - LMNL

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2
Q

What is the definition of a coma?

A

“ A state of unrousable psychological unresponsiveness in which the subjects lie with eyes closed and show no psychologically understandable response to external stimulus or inner need”

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3
Q

What does consciousness depend on?

A

An intact ascending reticular activating system to act as the alerting or awakening element of consciousness

Functioning cerebral cortex of both hemispheres which determines the content of that consciousness

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4
Q

Interesting graph

A
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5
Q

What are causes of reduced consciousness?

A

Toxic/metabolic states:

  • Hypoxia/hypercapnia/sepsis/hypotension
  • Drug intoxication/renal or liver failure
  • Hypoglycaemia, ketoacidosis

Seizures

Damage to reticular activating system

Causes of raised intracranial pressure

(tumour, stroke, EDH, SDH, SAH, hydrocephalus)

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6
Q

What is meant by a persistent vegetative state?

A

Brainstem recovers to a considerable extent but there is no evidence of recovery of cortical function

Arousal and wakefulness but the patient does not regain awareness or purposeful behaviour of any kind

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7
Q

What is locked in syndrome?

A

The patient has total paralysis below the level of the third nerve nuclei and can only open, elevate and depress the eyes

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8
Q

How do you manage a patient who is in a coma?

A

Airway

Breathing

Circulation

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9
Q

How can breathing give a clue as to the reason for the coma?

A

Depressed respiration - drug overdose, metabolic disturbance

Increased respiration - hypoxia, hypercapnia, acidosis

Fluctuating respiration - brainstem lesion

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10
Q

What are other means to try and determine the cause of coma?

A

Blood samples - glucose (hypoglycaemia), biochemistry, haematology (sepsis?ketoacidosis), blood gas (hypoxia, hypercapnia)

Toxicology

HISTORY - predictable progression of an underlying disease?

  • unpredicatable event of a patient with a previosuly known disease
  • Totally unexpected event - head injury, sudden collapse, limb twitching, previous history of drug or alcohol abuse?
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11
Q

What do you have to examine and monitor for a patient in a coma?

A

Temperature

Heart rate, Blood Pressure, CVS

Respiration

Skin, breath

Abdomen

Meningism

Fundal examination

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12
Q

How do you assess a coma?

A

Glasgow coma scale

Brainstem function

Motor function and reflexes

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13
Q

What are the parts of the glasgow coma scale?

A

Eye opening:

Spontaneous 4

To speech 3

To pain 2

None 1

Best verbal response:

Orientated 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

Best motor response:

Obeying Commands 6

Localising to pain 5

Withdrawing from pain 4

Flexing to pain 3

Extending to pain 2

None 1

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14
Q

What is defined as being in a coma according to the glasgow coma scale?

A

“Patients who fail to show eye opening in response to voice, perform no better than weak flexion in response to pain and make, at best, only unrecognisable grunting noises in response to pain are regarded as being in coma”

Eye opening 2 or less

Verbal response 2 or less

Motor response 4 or less

GCS equal or less than 8

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15
Q

which cranial nerves are required for the following assessments of the brainstem function?

Pupillary reactions

Corneal responses

Spontaneous eye movements

Oculocephalic responses (Doll’s eye) - eyes move to contralateral direction of head movement

Oculovestibular responses - hot or cold water is placed in into the ear, result is nystagmus or occular deviation (hot water causes deviation upwwards and cold water casues deviation downwards)

Respiratory pattern

A

Brainstem function

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16
Q

What will the temporal lobe pushing on the midbrain cause?

A

Will cause unilateral pupil dilation

17
Q

Will meningism have focal brainstem or lateralising cerebral signs?

18
Q

What can be the cause of coma without focal or lateralising signs and without meningism

A

Anoxic/ ischaemic conditions

Metabolic disturbances

Intoxications

Systemic infections

Hyperthermia/ Hypothermia

Epilepsy

19
Q

What is the investigation for patient in coma without focal or lateralising signs and without meningism?

A

Toxicology screen including alcohol level

Measure blood sugar and electrolytes

Assess hepatic and renal function

Acid - base assessment and blood gases

Measure blood pressure

Consider carbon monoxide poisoning

20
Q

What is meningism?

A

Set of symptoms similar to those of meningitis but not caused by meningitis. Meningism involves the triad (3-symptom syndrome) of nuchal rigidity (neck stiffness), photophobia (intolerance of bright light), and headache.

21
Q

What are the causes of coma with meningism?

A

SAH

Meningitis

Encephalitis

22
Q

What are investigations for patients in coma and meningism?

A

CT head scan

Lumbar puncture:

  • Appearance
  • Cell count
  • Glucose level
  • Capsular antigen tests
23
Q

What are the causes of coma with focal brainstem or localising cerebral signs?

A

Cerebral tumour

Cerebral haemorrhage

Cerebral infarction

Cerebral abscess

24
Q

What are the investigations for coma with focal brainstem or lateralising cerebral signs?

A

CT or MRI ALWAYS

Metabolic screens

Lumbar puncture

EEG

25
Q

Summary

26
Q

What are ‘medical’ causes of coma?

27
Q

What are the factors affecting the outcome of a coma?

A

Age

Cause of coma

Depth of coma

Duration of coma

Certain clinical signs, the most important of which are the brainstem reflexes

28
Q

How do you care for someone in a coma?

A

Maintenance of vital functions

Care of skin, avoidance of pressure sores

Attention to bladder and bowel function

Control of seizures

Prophylaxis of DVT, peptic ulceration

Prevention of contractures

Consider the “Locked - in” Syndrome

29
Q

What are the mechanisms whereby head injury results in focal neurological signs / epilepsy?

A
  1. Diffuse axonal injury
  2. Contusion
  3. Intracerebral haematoma
  4. Extra-cerebral haematoma (extra- dural and sub-dural)
30
Q

How do you manage a head injury?

A

Stabilise cervical spine

Airway/breathing/circulation

If GCS less than or equal to 8 then intubate and ventilate

Treat raised ICP

Cranial imaging - decompressive surgery or removal of haematoma

Neuro observation

31
Q

How do you treat raised ICP?

A

Surgery to releive pressure (haematoma, ventricular shunt)

Osmotic agents e.g. mannitol

Nurse with head at 30-45% (venous return)

Reduce pain

Maintain good PO2 reduce PCO2

Reduce metabolism (reduce temperature, barbituates)

MBChB - Y2 - Systems - Nervous System (48 decks)

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