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Neuro > Coma + PVS + Brain Death > Flashcards

Coma + PVS + Brain Death Flashcards

1
Q

Define Coma [3]

A

“State of unrousable psychologcial unresponsiveness” [1]

Eyes closed [1] & no perceivable response to external stimulus or inner needs [1]

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2
Q

Consciousness depends on 2 things [4]

A

Arousal:
Intact Ascending Reticular Activating System [1] to alert/awaken consciousness [1]

Awareness:
Functional Cerebral Cortex [1] to determine the content of your consciouness [1]

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3
Q

What could cause your GCS to fall (alter consciousness) [4]

A
  • Toxic/Metabolic states such as intoxication, hypoxia/hypercapnia, sepsis, hypotension, hypoglycaemia, acidosis
  • Seizures
  • Damage to Reticular Activating System
  • Raised ICP such as tumour, stroke, haematoma, SAH or hydrocephalus
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4
Q

Define a Persistent Vegetative State? [3]

Describe in terms of levels of wakefulness vs awareness [1]

A

After reduced consciousness (mainly comas) the Brain stem recovers to a considerable extent [1] but no recovery of coritcal function [1]

High wakefulness but very low awareness [1]

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5
Q

Define Locked in Syndrome? [3]

Describe in terms of levels of wakefulness vs awareness [1]

A

Total Paralysis below III nuclei so: [1]

  • Can open and vertically move eyes [1]
  • But cant move horizontal [1]

Both high wakefullness and awareness [1]

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6
Q

What causes locked in syndrome? [3]

A

Brainstem Strokes (e.g. Pontine Arteries)
Brainstem Lesions
Traumatic Brain Injury

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7
Q

Whats involved in resus for a patient with reduced consciousness?

A

ABCD
(Breathing patterns can indicate a specific condition)

Bloods (Glc, biochem, haematology, ABGs, toxicology)

BP/pulse/temp/IV access

Stabilise neck in case of trauma

Look for evidence of meningitis

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8
Q

Neuro exam of coma? [3]

A

GCS
Brainstem function
Motor function & reflexes

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9
Q

At what glasgow coma scale score do we call it Coma [1]

A

GCS 8 or less, specifically:
Eye - 2 or less (pain or none)
Verbal - 2 or less (grunting)
Motor - 4 or less (weak flexion)

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10
Q

How do we assess brainstem function? [6]

A

Brainstem reflexes:

  • Pupill reflexes (2&3)
  • Corneal Reflex (5 & 7)
  • Spontaneous eye movement (3/4/6)
  • Oculovestibular (Caloric Stimulation) (3/4/6/8)
  • Resp Pattern (Medullary Centres)
  • Oculocephalic (normal nystagmus) (3/4/6/8)
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11
Q

Causes of Coma without focal brainstem or lateralizing cerebral signs or meningism? [6]

A
  • Ischaemia
  • Metabolic
  • Intoxication
  • Epilepsy
  • Infection
  • Hyper/Hypothermia
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12
Q

How would you investigate someone with coma without focal signs or meningism? [5]

A 
Toxicology
Bloods
Hepatic/renal function
ABGs
BP
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13
Q

Causes of Coma - 3 broad categories

A

Meningism = SAH/meningitis/encephalitis

Focal brainstem or lateralizing signs = Tumour, infarct etc

No focal signs or meningism = Toxic(Alcohol)/metabolic(hypoxia)/systemic

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14
Q

How would you continue to care for a coma patient? [7]

A
  • Maintain their vital functions
  • Care for their skin, particularly pressure sores
  • Attend to bowel/bladder function
  • Control seizures
  • Prophylaxis for DVTs or Peptic ulcers
  • Prevent Contractures
  • Assess for Locked in Syndrome
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15
Q

What results of a head injury could lead to focal neuro signs or epilepsy? [3]

A
  • Diffuse axonal injury
  • contusions
  • Haematoma (intracerebral, extradural, subdural)
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16
Q

How do you manage a head injury? [5]

A
  • Stabilize the C spine
  • ABC
  • If in coma (GCS <8) intubate and ventilate
  • Treat raised ICP
  • CT (may need surgery)
17
Q

Coma with focal brainstem or lateralising cerebral signs differentials [4]

A

Cerebral tumor
Cerebral hemorrhage
Cerebral infarction
Cerebral abscess

18
Q

Coma with focal brainstem or lateralising cerebral signs - investigations [4]

A 
CT or MRI obligatory
If not diagnostic then investigate other causes of coma:
- Metabolic screens
- LP
- EEG
19
Q

Medical causes of coma lasting more than 5h [4]

A

Drug ingestion eg alcohol
Hypoxia secondary to MI
CVA
Metabolic eg diabetes, hepatic failure, renal failure, sepsis

20
Q

Factors affecting prognosis of coma [4]

A

Age
Cause
Depth
Duration

21
Q 
GCS
Total score?
Lowest score?
Score breakdown:
Motor?
Verbal?
Eyes?
A

Total score 15
Lowest score 3

Motor 6
Verbal 5
Eye 4

22
Q

GCS

Describe what qualifies for motor scoring

A
  1. Obeys commands
  2. Localises to pain
  3. Withdraws from pain
  4. Abnormal flexion to pain (decorticate posture)
  5. Extending to pain
  6. None
23
Q

GCS

Describe what qualifies for verbal scoring

A
  1. Orientated
  2. Confused
  3. Words
  4. Sounds
  5. None
24
Q

GCS

Describe what qualifies for eye opening scoring

A
  1. Spontaneous
  2. To speech
  3. To pain
  4. None
25
Q

Criteria for brain stem death testing [4]

A

Deep coma of known aetiology.
Reversible causes excluded
No sedation
Normal electrolytes

26
Q

Testing for brain death: who [4]

A

The test should be undertaken by two appropriately experienced doctors on two separate occasions.
Both should be experienced in performing brain stem death testing and have at least 5 years post graduate experience.
One of them must be a consultant.
Neither can be a member of the transplant team (if organ donation contemplated).

27
Q

Tests for brain death [6]

A 
Pupillary light reflex: fixed, non responsive to light
Corneal reflex: none
Oculo-vestibular reflexes
Supra-orbital pressure: no response
Cough or gag reflex: none
Respiratory effort
28
Q

How to determine no oculovestibular reflex?

A

no eye movements following slow injection of at least 50mL ice cold water into each ear in turn (caloric test)

29
Q

How to determine no respiratory effort

A

no observed respiratory effort in response to disconnection of ventilator for long enough (typically 5 min) to ensure PaCO2 >6.0kPa (6.5 in chronic CO2 retention); adequate oxygenation is ensured by pre-oxygenation and diffusion oxygenation during disconnection (so brainstem respiratory centre not challenged by ultimate anoxic drive stimulus)

Neuro (42 decks)

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