Evaluation of Comatose Patient Lecture Flashcards
If a patient is conscious and responsive, how should you objectively describe them?
Awake, alert and appropriate
If a patient is unresponsive, how should you report/describe this?
Report how they respond to various stimuli starting with the LEAST invasive
Describe verbal stimuli of an unconscious patient
- Start by calling pt’s name
- Describe how they respond
- See if they can follow commands (stick out your tongue, open your eyes)
Which verbal commands are easiest to follow?
Midline commands
What are examples of midline commands?
Stick out your tongue
Open your eyes
If a patient can follow midline commands, what should be tried next?
Peripheral commands
lift your R hand, squeeze my finger
What are examples of peripheral commands?
Lift your R hand
Squeeze my finger
Example of a complex or 2 step command?
Squeeze your eyes shut and hold up 2 fingers
Stimuli from least invasive to most invasive for unconscious patient
- Visual
- Verbal
- Tactile
- Noxious (painful)
Describe tactile stimuli
- Tapping pt on shoulder or chest
- More invasive than verbal stimuli
Describe noxious stimuli and how they can be delivered
- More invasive than verbal or tactile stimuli
- Pressure on base of nailbed
- Pressure on superior aspect of orbit
- Nipple tweak/pinch
Possible patient responses to noxious stimuli?
- Appropriate (moves to push stimulus away)
- Moan/move without purpose
- Posturing
Types of posturing responses to noxious stimuli
- Decorticate
2. Decerebrate
What is decorticate posturing?
- Flexor rigidity w/adduction of shoulder, flexion of elbow/wrists/fingers
- IR of legs w/plantar flexion of feet
What does decorticate posturing indicate?
Destructive lesion in cerebral hemispheres at or near level of corticospinal tracts
What is decerebrate posturing?
- Extensor rigidity w/adduction of shoulder, extension of elbow
- Pronated wrists, flexed fingers
- Legs extended, foot plantar flexed
What does decerebrate posturing indicate?
Brainstem level lesion usually in pons or midbrain
Is posturing unilateral or bilateral?
Could be either
Which posturing carries a worse prognosis?
Decerebrate
Poorest prognostic indicator to noxious stimuli?
Unresponsive
worse than posturing
Describe CN exam of comatose patient
LIMITED
- 3/4/6 tested for “dolls eyes” and pupillary response
- 5 and 7 tested by corneal reflex
DTRs of comatose patient
- Can be tested but not very helpful in a profoundly comatose pt
- Can be found even in brain dead pts
Describe “dolls eyes” test
- Tests for oculocephalic reflex (CN 3/4/6) in comatose patient
- Rapidly turn head to right and then left
- Pt should maintain gaze straight ahead or toward contralateral side despite head movement (dolls eyes present)
- If you get no response, this is absent Dolls eyes
CN 3 palsy in Dolls eye test
Affected eye will move laterally but NOT medially with Dolls maneuver
CN 6 palsy in Dolls eye test
Eye will move medially but NOT laterally
Doll’s eyes test should NOT be performed in which patients?
Possible cervical fractures or responsive/awake patient
Motor, sensory, cerebellar testing of comatose patient
CANNOT be done
Describe Glasgow coma scale
- Method to quantitatively assess comatose patient
- Scored based on motor, verbal, and eye opening responses
Describe GCS scores
- Lower score is worse prognosis
- Pts w/initial score of 3-4 have 95% chance of dying or remaining in vegetative state
- Pts w/score of 3-8 are considered comatose
What GCS scores are considered “comatose”?
3-8
