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Neurology > Lecture 34 Coma, Persistent Vegetative State, Brain Death > Flashcards

Lecture 34 Coma, Persistent Vegetative State, Brain Death Flashcards

1
Q

Define a Coma

A

• A state of unrousable psychological unresponsiveness in which the subjects lie with eyes closes and show no psychologically understandable response to external stimulus of inner need

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2
Q

A GCS score of below what is serious and requires quick intervention

A

<8

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3
Q

What does consciousness depend on

A
  1. An intact ascending reticular activating system to act as the alerting or awakening element of consciousness
  2. A functioning cerebral cortex of both hemispheres which determined the content of that consciousness
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4
Q

What part of the brain is responsible for arousal

A

Reticular activating system

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5
Q

What part of the brain is responsible for awareness of environment

A

Cerebral hemispheres

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6
Q

Causes of reduced GCS

A

Toxic/metabolic states
Seizures
Damage to reticular activating system
Intracranial pressure increase

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7
Q

What causes toxic/metabolic states

A

o Hypoxia/hypercapnia/sepsis/hypotension
o Drug intoxication/renal or liver failure
o Hypoglycaemia, ketoacidosis

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8
Q

What causes raised intracranial pressure

A 
o	Tumour
o	Stroke
o	EDH
o	SDH
o	SAH
o	Hydrocephalus
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9
Q

What is involved in resuscitation when a patient has a reduced GCS

A

• Airway
• Breathing
o Depressed respiration- drug OD, metabolic disturbance
o Increased respiration- hypoxia, hypercapnia, acidosis
o Fluctuating respiration- brainstem lesion
• Circulation
• Blood samples
o Glucose
o Biochemistry
o Haematology
o Blood gas
o Toxicology
• Establish baseline blood pressure, pulse, temperature, IV access and stabilise the neck
• Examine for evidence of meningitis- treat on suspicion

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10
Q

What is involved in the history of patient with reduced GCS

A

• Predictable progression of underlying illness
• Unpredictable event in patient with previously known disease
• Totally unexpected event
o Head injury
o Sudden Collapse
o Limb twitching
o Previous history of drug or alcohol abuse

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11
Q

What is involved in examination and Monitoring of a patient

A
  • Temperature
  • HR, BP and CVS
  • Respiration
  • Skin, Breath
  • Abdomen
  • Meningism
  • Fundal examination
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12
Q

What is involved in the neurological assessment of coma

A

GCS
Brainstem function
Motor function and reflexes

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13
Q

How do you assess. brainstem function

A

Cranial nerves

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14
Q

What cranial nerves are assessed for pupillary reactions

A

II

III

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15
Q

What cranial nerves are assessed for corneal responses

A

V

VII

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16
Q

What cranial nerves are assessed for spontaneous eye movements

A

III, IV, VI

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17
Q

What cranial nerves are assessed for Doll’s eye

A

III, IV, VI, VIII

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18
Q

What cranial nerves are assessed for Oculovestibular responses

A

II, IV, VI, VIII

19
Q

What cranial nerves are assessed for respiratory pattern

A

Medullary centre

20
Q

How is motor function assessed

A

Motor response
Muscle tone
Tendon reflexes
Seizures

21
Q

if a patient is:
In a coma
No meningism
No focal brainstem or materialising cerebral signs

What are the causes

A

Toxic/metabolic/systemic

22
Q

if a patient is:
In a coma
Has meningism
No focal brainstem or materialising cerebral signs

What are the causes

A

SAH
Meningitis
Encephalitis

23
Q

if a patient is:
In a coma
Has meningism
Has focal brainstem or materialising cerebral signs

What are the causes

A

Focal cerebral
Tumour
Infarct

24
Q

What investigations would you carry out for Coma without focal signs, lateralising signs or meningism

A
  • Toxicology screen including alcohol level
  • Measure blood sugar and electrolytes
  • Assess hepatic and renal function
  • Measure blood pressure
  • Consider Carbon monoxide poisoning
25
Q

What investigations would you carry out for Coma without focal or lateralising signs but with meningism

A 
•	CT head scan
•	Lumbar puncture
o	Appearance
o	Cell count
o	Glucose level 
o	Capsular antigen tests
26
Q

What investigations would you carry out for Coma with focal brainstem or lateralising cerebral signs

A 
•	CT or MRI
•	If CT/MRI not diagnostic
o	Metabolic screens
o	Lumbar puncture
o	EEG
27
Q

Medical causes of Coma lasting more than 5 hours

A
  • Drug ingestion + alcohol
  • Hypoxia- secondary to MI
  • Haemorrhage or infarction
  • Metabolic- diabetes, hepatic failure, renal failure, sepsis, hypercapnia/hypoxia
28
Q

What is locked in syndrome

A
  • Total paralysis below the level of the 3rd nerve nuclei

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

29
Q

Describe the continuing care of patients in 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
  • Consider the locked in syndrome
30
Q

How can a head injury lead to focal neurological symptoms/ Epilepsy

A
  1. Diffuse axonal injury
  2. Contusion
  3. Intracerebral haematoma
  4. Extra-cerebral haematoma
    • Extra-dural haematoma
    • Subdural haematoma
31
Q

On a CT what would you see in a subdural and extradural haematoma

A
  • Extradural- concave/convex lens shape

* Subdural- ellipse convex

32
Q

How is a head injury managed

A
  • Stabilise cervical spine
  • ABC
  • If GCS <8 intubation and ventilation
  • Treat raised ICP
  • Cranial Imaging- may need decompressive surgery or removal of haematoma
  • Neuro observation
33
Q

Name treatment for raised ICP

A
  1. Surgery- haematoma, ventricular shunt (hydrocephalus)
  2. Osmotic agents e.g. mannitol
  3. Head at angle 30-45 (venous return)
  4. Reduce pain
  5. Maintain good PO2 and reduce PCO2
  6. Reduce metabolism (reduce temp, barbiturates)
34
Q

What is a non-epileptic attack

A

These seizures look like epileptic attacks but are not caused by electrical activity in the brain

35
Q

What can cause non-epileptic attacks

A

o Psychiatric history
o Recent stress
o Young F>M

36
Q

What are the clinical features of a non-epileptic attack

A 
o	Sinusoidal tremor not jerking
o	Pelvic thrusting
o	Side to side head movements
o	Eyes closed and resists opening
o	Partial responsiveness
37
Q

What is the ROSIER scale

A

Recognition of Stroke in the Emergency Room

38
Q

What score on the ROSIER scale would suggests a stroke

A

> 0

39
Q

What score is given to seizure activity and LOC in a ROSIER scale

A

-1

40
Q

What score is given to face, leg or arm weakness and speech or visual disturbances

A

+1

41
Q

What is a Hemicraniectomy

A

• Decompressive surgery for severe cerebral swelling post-stroke

42
Q

Post stroke how long does it take for the GCS score to fall to prompt a Hemicraniectomy

A

24-72 hours

<60 years old

43
Q

What can be the cause of haemorrhagic stroke

A

• Hypertensive- small perforating arteries in the brain stem, basal ganglia and cortex

Neurology (44 decks)

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