Coma, persistent vegetative state, brain death

Question 1

What score on the GCS is worrying?

Answer 1

8 or below

eye opening - 2 or less
verbal response - 2 or less
motor response - 4 or less

Question 2

What does consciousness depend on

Answer 2

intact ascending reticular activating system - act as the alerting/awakening element of consciousness

functioning cerebral cortex of both hemispheres - awareness of environment

Question 3

What are some causes of a decreased GCS

Answer 3

toxic/metabolic states - hypoxia/ sepsis etc, drug intoxication/renal or liver failure, hypoglycaemia, ketoacidosis

seizures

damage to reticular activating system

causes of raised ICP - tumour, stroke, haematomas, hydrocephalus

Question 4

Why might a person have fluctuating respiration? (1)

Answer 4

brainstem lesion

Question 5

Why might a person have depressed respiration? (2)

Answer 5

drug overdose

metabolic disturbance

Question 6

Why might a person have increased respiration? (3)

Answer 6

hypoxia
hypercapnia
acidosis

Question 7

After you carry out ABC what else are you going to check?

Answer 7

bloods - glucose, biochemistry, blood gas, toxicology

establish baseline BP, pulse, temperature, I.V access and stabilise the neck

examine for evidence of meningitis

Question 8

Neurological assessment of Coma (3)

Answer 8

GCS
Brainstem function
Motor function + reflexes

Question 9

How is brainstem function tested?

Answer 9

Cranial nerve examination

Pupillary reactions - II+III
Corneal responses - V+VII
Spontaneous eye movements - III, IV, VI
Oculocephalic reflex - III, IV, VI, VIII
Respiratory pattern - medullary centre

Question 10

What is the Oculocephalic/ ‘doll’s eye’ reflex?

Answer 10

test of brain function in comatose persons

You move their head side to side.

In a positive / normal reflex, the eyes move in the direction opposite to that of the head movement

Question 11

What do you test to check Motor function?

Answer 11

motor response
muscle tone
tendon reflexes
seizures

Question 12

What is Meningism?

Answer 12

the clinical syndrome of headache, neck stiffness, and photophobia, often with nausea and vomiting.

Question 13

Causes of a coma without focal or lateralising signs and without meningism (6)

Answer 13

Intoxications

anoxic/ischaemic conditions

metabolic disturbances

systemic infections

epilepsy

hyperthermia/hypothermia

Question 14

Suspected causes of a coma without focal or lateralising signs but with meningism

Answer 14

subarachnoid haemorrhage

meningitis

encephalitis

Question 15

What investigations would you do for coma without focal or lateralising signs but with meningism

Answer 15

CT head scan

lumbar puncture - appearance, cell count, glucose level

Question 16

Suspected causes of coma with focal brainstem or lateralising cerebral signs

Answer 16

cerebral tumour
cerebral haemorrhage
cerebral infarction
cerebral abscess

do CT or MRI
if these aren’t diagnostic think other causes of coma - EEG, lumbar puncture etc

Question 17

Common causes of coma lasting > 5 hours (4)

Answer 17

40% drug ingestion +/alcohol

25% hypoxia - 2ndry to MI

20% cerebrovascular event - haemorrhage or infarction

15% metabolic - diabetes, hepatic failure, renal failure, sepsis

Question 18

What is ‘locked-in’ syndrome?

Answer 18

Patient has total paralysis below the level of the 3rd nerve nuclei and although able to open, elevate and depress the eyes has no horizontal eye movements and no other voluntary eye movement

Question 19

How is care continued throughout the time a patient is in a coma?

Answer 19

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 - muscles/tendons remaining tight for too long

Question 20

Head injuries can lead to focal neurological signs/epilepsy due to..

Answer 20

diffuse axonal injury - scattered lesions in W matter tracts as well as G matter occur over a widespread area.

contusion - bruising

intracerebral haematoma

extracerebral haematoma - extra-dural or sub-dural

Question 21

What does an extradural haematoma look like on CT

Answer 21

concave/ convex (lens) shaped white pocket

Question 22

How is increased ICP treated

Answer 22

surgery to relieve pressure

osmotic agents

reduce pain

maintain good PO2 and reduce PCO2

reduce metabolism

Question 23

what is the ROSIER scale?

Answer 23

used to differentiate patients with stroke and stroke mimics

it’s on a scale from -2 to +5

-1 for seizure activity or loss of consciousness

score of >0 predicts stroke

Question 24

What is Hemicraniectomy surgery

Answer 24

decompressive surgery for severe cerebral swelling post-stroke