Coma - Tucker

Question 1

___ - Arousal / level of alertness

___- Ability to perceive stimuli in different domains

Answer 1

Awake - Arousal / level of alertness

Aware - Ability to perceive stimuli in different domains

Question 2

Aphasia and neglect are examples of FOCAL loss of ___

Answer 2

Aphasia and neglect are examples of FOCAL loss of awareness

Question 3

Coma

A state of ____ unresponsiveness. Eyes will be ___, nonverbal, no purposeful ___.

This is a state in __ and seen acutely.

Answer 3

Coma

A state of unarousable unresponsiveness. Eyes will be closed, nonverbal, no purposeful movements.

This is a state in transition and seen acutely.

Question 4

Duration:

Usually last no more than __ to ___ weeks - “a ____ state”

Possible Outcomes (4)

Answer 4

Duration
Usually last no more than 2- 4 weeks - “a transitional state”

Possible Outcomes:

1. Vegetative State
2. MCS
3. Brain death
4. Consciousness regained

Question 5

Causes of Comas (5) LIMPS

1. Lesions:

Lesions in the upper brainstem, bilateral thalami, or bilateral cerebral cortex can cause coma due to impairment of ARAS and related pathways/ projections. ARAS Projections

2. Structural Brain Injury

• Bilateral Hemispheric Involvement (can start unilateral –>midline shift) 2. Brainstem 3. Cerebellum Displacing 4. Brains

3. Acute Metabolic/Toxic HIDEOUS PT:

H – hepatic dysfunction

I – infectious

D – drug effects or withdrawal syndromes

E – electrolyte abnormalities

O – oxygenation and ventilation

U – uremia

S – sugar (hypo or hyperglycemia)

P – pH, acid/base status

T – thyroid

4. Inadequate Cerebral Perfusion

5. Seizures

Answer 5

Causes of Comas (5) LIMPS

1. Lesions:

Lesions in the upper brainstem, bilateral thalami, or bilateral cerebral cortex can cause coma due to impairment of ARAS and related pathways/ projections. ARAS Projections

2. Structural Brain Injury

• Bilateral Hemispheric Involvement (can start unilateral –>midline shift) 2. Brainstem 3. Cerebellum Displacing 4. Brains

3. Acute Metabolic/Toxic HIDEOUS PT:

H – hepatic dysfunction

I – infectious

D – drug effects or withdrawal syndromes

E – electrolyte abnormalities

O – oxygenation and ventilation

U – uremia

S – sugar (hypo or hyperglycemia)

P – pH, acid/base status

T – thyroid

4. Inadequate Cerebral Perfusion

5. Seizures

Question 6

Possible Outcomes of Coma

1. Vegetative State - One possible outcome of coma.

Intact __ but lack of ____.

No reproducible, purposeful responses to ___.

They can ____ but it is in a non-purposeful way.

They cannot push me away if I pinch them, etc.

Intact ___ __/__-___ cycles

Causes

1. ___
2. ___
3. __ __ injury

Types of Vegetative States:

1. ___ __ __ - After 1 month
2. ___ - 3 months after non-traumatic cause like after __ __
   or - ___ months after TBI

Answer 6

Possible Outcomes of Coma

1. Vegetative State - One possible outcome of coma.

Intact arousal but lack of AWARENESS Symptoms

No reproducible, purposeful responses to stimuli.

They can move but it is in a non-purposeful way.

They cannot push me away if I pinch them, etc.

Intact cyclical arousal/sleep-wake cycles

Causes

1. TBI = traumatic brain injury
2. DAI = diffuse axonal injury
3. Hypoxic brain injury

Types of Vegetative States:

1. PVS (persistent vegetative state) - After 1 month
2. Permanent- 3 months after non-traumatic cause like after cardiac arrest

or -12 months after TBI

Question 7

Possible Outcome of Coma

2. Minimally Conscious State
   - Severely altered ____ with ___ behavioral evidence of self or environmental ____ (at least ___ (time)). They can track sometimes, or grab onto an item sometimes.

Diagnosis using __ and __ may assist in this evaluation

Symptoms: ___ contact, tracking, __ __ to voice, localizing stimuli, ___ object, speaking inaccurately.

MSC does not have __ __.

-May be chronic - or Permanent

__/___ cycle is intact

Answer 7

Possible Outcome of Coma

2. Minimally Conscious State
   - Severely altered consciousness with reproducible behavioral evidence of self or environmental awareness (at least intermitently (time)). They can track sometimes, or grab onto an item sometimes.

Diagnosis using PET and fMRI may assist in this evaluation

Symptoms: eye contact, tracking, head turning to voice, localizing stimuli, holding object, speaking inaccurately.

MSC does not have time frame.

Sleep/Wake Cycle in intact

Question 8

Things that look like coma but are not:

1. ___: catatonia, malingering, conversion
2. ____: lesion in ventral pons - Loss of bilateral corticospinal and corticobulbar tracts (patients are quadriplegic with no ability to speak) - Caused by pontine infarct, hemorrhage, or trauma - Consciousness intact but minimal ability to interact
3. ____: bilateral medial frontal lobes - Difficulty with motivation, initiation, and executive function - ___wake, ___ to track, no ____ response to stimuli - Not ___and not ___
4. ____- acute confusional state with impaired attention, very common in hospital

Answer 8

Things that look like coma but are not:

1. Psychogenis: catatonia, malingering, conversion
2. Locked-in: lesion in ventral pons - Loss of bilateral corticospinal and corticobulbar tracts (patients are quadriplegic with no ability to speak) - Caused by pontine infarct, hemorrhage, or trauma - Consciousness intact but minimal ability to interact
3. Akinetic Mutism: bilateral medial frontal lobes - Difficulty with motivation, initiation, and executive function - Awake, able to track, no motor response to stimuli - Not moving and not talking
4. Delirum- acute confusional state with impaired attention, very common in hospital

Question 9

How to define irreversible and loss of all function?

Key is anatomic explanation for loss of brain & brainstem functions
Final common pathway = __ __ arrest from __ ___.

So ___ must be higher than ___.

CPP = ___ means NO __ ___.

Cardinal Findings: (in this order)

1. Absence of __ __
2. ___ test
   - DNC is a CLINICAL diagnosis

Prerequisites, exam, & apnea test in that order

Absence of clinical brain function when the proximate cause is __ and demonstrably ___

__ ___: In certain populations, if you cannot do part of the apnea exam, i.e. had a car accident and can’t see pupils, you can do the this test.
__ __ involves:

1. __ __ __ study
2. _ __

Answer 9

How to define irreversible and loss of all function?

Key is anatomic explanation for loss of brain & brainstem functions
Final common pathway = cerebral circulatory arrest from intracranial hypertension

So ICP must be higher than MAP

CPP = 0 means NO cerebral perfusion

Cardinal Findings: (in this order)

1. Absence of brainstem reflexes
2. Apnea test
   - DNC is a CLINICAL diagnosis

Prerequisites, exam, & apnea test in that order

Absence of clinical brain function when the proximate cause is known and demonstrably irreversible

Ancillary Test: In certain populations, if you cannot do part of the apnea exam, i.e. had a car accident and can’t see pupils, you can do the ancillary test.

Ancillary Test involves:

1. Nucleoar medicine flow study

2. Doppler ultrasound

Question 10

Tools to Test: Apnea Testing

The apnea test is a mandatory examination for determining __ __

• Pupils nonreactive
• Absent corneals
• Absent oculocephalics and oculovestibular
• No facial movement
• Absent gag and cough
• No motor to painful central and peripheral stimuli
• Spinal reflexes like triple flexion are allowed
• Apnea test looking for Pa___ rise by ___mmHg or ≥ __mmHg without spontaneous respiratory efforts

Answer 10

Tools to Test: Apnea Testing

The apnea test is a mandatory examination for determining brain death (BD)

• Pupils nonreactive
• Absent corneals
• Absent oculocephalics and oculovestibular
• No facial movement
• Absent gag and cough
• No motor to painful central and peripheral stimuli
• Spinal reflexes like triple flexion are allowed
• Apnea test looking for PaCO2 rise by 20mmHg or ≥ 60mmHg without spontaneous respiratory efforts