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The Nervous System: Pathology > Coma, Persistent Vegetative State, BrainDeath > Flashcards

Coma, Persistent Vegetative State, BrainDeath Flashcards

1
Q

What two factors does consciousness depend upon

A

An intact ascending reticular activating system

Functional cerebral cortex of both hemispheres

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2
Q

What is the function of the reticular system in consciousness

A

Arousal -acts as the alerting or awakening element of consciousness

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3
Q

What is the function of the cerebral cortex in consciousness

A

Awareness of the environment -determine the content go consciousness

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4
Q

What is the affect of the two components of consciousness in a coma

A

Low level of consciousness (wakefulness) - RAS

Low content of consciousness (awareness) - CH

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5
Q

What is the affect of the two components of consciousness in a vegetive state

A

Low content of consciousness (awareness)

High level of consciousness (wakefulness)

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6
Q

What are potentially causes of decreased consiousness

A

Toxic metabolic stress
eg ischaemia, hypoglycaemia, hepatic or renal failure

Seizures

Damage to the reticular activating system

Causes of raised intracranial pressure

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7
Q

What are causes of toxic metabolic stress that results in decreased consciousness

A

Hypoxia/hypercapnia/sepsis/hypotension

Drug intoxication/renal or liver failure

Hypoglycaemia, ketoacidosis

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8
Q

What are causes of raised intracranial pressure that results in decreased consciousness

A 
tumour, 
stroke, 
Extra dural haematoma
Sub dural haematoma
Subarachnoid haemorrhage 
hydrocephalus
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9
Q

What pathological affects can result in decreased consciences

A

Diffuse hemisphere damage

Focal damage

Brainstem involvement

  • herniation
  • compression (mass)
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10
Q

Define 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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11
Q

What is the pathology of a persistent vegetative state

A

A state in which the brain stem recovers to a considerable extent but there is no evidence of recovery of cortical function

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12
Q

What is the affect of persistent vegetive state

A

There is arousal and wakefulness but the patient does not regain awareness or purposeful behaviour of any kind

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13
Q

What is the affect of “locked in” syndrome

A

able to open, elevate and depress the eyes, nut has no horizontal eye movements and no other voluntary eye movement

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14
Q

What does the diagnosis of locked in syndrome depend upon

A

recognising that the patient can open their eyes voluntarily and signal numerically by eye closure

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15
Q

Define resuscitation

A

the action or process of reviving someone from unconsciousness or apparent death

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16
Q

What should first be considered in resuscitation

A

ABC
Airway
Breathing
Circulation

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17
Q

Why is it important to listen to breathing pattern

A

can give indication to the problem

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18
Q

What doe depressed respiration potentially indicate

A

Drug overdose

metabolic disturbance

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19
Q

What does increased respiration potentially indicate

A

Hypoxia
Hypercapnia
acidosis

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20
Q

What does a fluctuating respiration potentially indicate

A

Brainstem lesion

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21
Q

What is important to retrieve from unconscious patient to help determine cause of state

A

Blood sample:

Glucose, biochemistry, haematology, blood gas and toxicology

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22
Q

What is additional steps in resuscitation

A

Establish base line (BP, pulse, temp)

Find IV access

Stabilise neck

examine evidence for meningitis

23
Q

Why is it important to gain a history of unconscious patients

A

if this was a predictable progression of underlying illness

An unpredictable event in previous known disease

A totally unexpected event in the patient

24
Q

If a totally unexpected event in patient history what additional information do you need to gather

A

Head injury
sudden collapse
limb twitching
previous history of drug or alcohol abuse

25
Q

What do you examine and monitor in a unconscious patient

A 
Temperature
Heart rate, Blood Pressure, CVS
Respiration
Skin, breath
Abdomen
Meningism
Fundal examination
26
Q

What are three version for neurological assessment of coma

A

Glasgow Coma Scale

Brainstem Function

Motor Function + Reflexes

27
Q

What is the Glasgow coma scale for eye opening

A

Spontaneous 4
To speech 3
To pain 2
None 1

28
Q

What is the Glasgow coma scale for best verbal response

A 
Orientated				5
Confused				4
Inappropriate words			3
Incomprehensible sounds		2
None					1
29
Q

What is the Glasgow coma scale for best motor response

A 
Obeying Commands		6
Localising to pain			5
Withdrawing from pain		4		
Flexing to pain			3
Extending to pain			2
None					1
30
Q

How does the Glasgow coma scale define if someone is in a coma

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”

31
Q

What is the Glasgow coma scale score of a coma

A

Eye opening - 2 or less
Verbal response - 2 or less
Motor response - 4 or less

GCS <8 =

32
Q

How do we access brain stem function

A

Pupillary reactions

Corneal responses

Spontaneous eye movements

Oculocephalics response (Doll’s eye)

Oculovestibular responses

Respiratory pattern

33
Q

What cranial nerves does pupillary reaction test in the brain stem

A

CN II + III

34
Q

What cranial nerves does corneal response test in the brain stem

A

CN V + VII

35
Q

What cranial nerves does spontaneous eye movement test in the brain stem

A

CN III, IV, VI

36
Q

What cranial nerves does oculocephalic reflex response test in the brain stem

(tested by holding the eyes open and rotating the head from side to side or up and down)

A

CN III, IV, VI, VIII

37
Q

What does respiratory pattern access in the brainstem

A

Medullary centres

38
Q

How do you access motor function in an unconscious patient

A

Motor response
Muscle tone
tendon reflex
seizure evidence

39
Q

What is the potential cause of coma without focal or lateralising signs and without meningism

A

Anoxic/ ischaemic conditions

Metabolic disturbances

Intoxications

Systemic infections

Hyperthermia/ Hypothermia

Epilepsy

40
Q

What is the investigations for a coma without focal or lateralising signs and without meningisml

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

41
Q

What is the causes of a Coma without focal or lateralising signs but with meningism

A

Subarachnoid Haemorrhage

Meningitis

Encephalitis

42
Q

What is investigations for Coma without focal or lateralising signs but with meningism

A

CT Head scan

Lumbar puncture

43
Q

What is assessed in the lumbar puncture in a coma with meningism

A

Appearance of CSF (cloudy)

Cell count

Glucose level

Capsular antigen tests

44
Q

What is the potentially causes of a coma with focal brainstem or lateraling cerebral signs

A

Cerebral tumour

Cerebral haemorrhage

Cerebral infarction

Cerebral abscess

45
Q

Investigations for Coma with focal brainstem or lateralising cerebral signs

A

CT or MRI obligatory

investigate as for other causes of coma:

  • metabolic screens
  • lumbar puncture
  • EEG
46
Q

What is the medical cause of comas lasting more than 5 years

A

Drug ingestion ± alcohol (40%)

Hypoxia e.g. secondary to MI (25%)

Cerebrovascular event, either haemorrhage or infarction (20%)

Metabolic e.g. diabetes, hepatic failure, renal failure, sepsis, hypercapnia/hypoxia (15%)

47
Q

What factors affect 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 brain stem reflexes

48
Q

What is the predicted outcome of a non traumatic coma

A

15% of patients incoma for more than 6 hours will make a good or moderate recovery

85% will die, remain vegetive or reach a state of severe disability in which they remain dependent

49
Q

What is the management of patients 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 (hardening of muscle, tendon tissue etc)

50
Q

What should be considered in coma patients

A

“locked-in” syndrome

51
Q

Head injury can lead to focal neurological signs/epilepsy as causes the development of what

A

Diffuse axonal injury

Contusion (bruise)

Intracerebral haematoma

Extra-cerebral haematoma

  • Extra-dural haematoma
  • Sub-dural haematoma
52
Q

How do you diagnose a head injury

53
Q

What is the management of a head injury

A

Stabilise cervical spine

Airway/Breathing/Circulation

If GCS≤8 - intubation+ventilation

Treat raised ICP

Cranial imaging - may need decompressive surgery or removal of haematoma

Neuro observation

54
Q

What is 6 different ways in treating and manage increased intracranial pressure

A

Surgery to relieve pressure (heamatoma, 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, barbiturates)

The Nervous System: Pathology (25 decks)

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