Coma, Persistent Vegetative State and Brain Death

Question 1

When is a person considered to be in a come?

Answer 1

Glasgow Coma Scale Score: less than or equal to 8

GCS lower than 9

Question 2

Describe the maximum responsiveness to GCS testing a person in a coma would demonstrate?

Answer 2

• Fails to open eyes in response to voice
• No more than weak flexion in response to pain
• No more than unrecognizable grunting noises in response to pain

Question 3

What does consciousness depend on?

Answer 3

1. AROUSAL - An intact Ascending Reticular Activating System (ARAS) - nuclei responsible for initiating wakefulness and sleep-wake transitions
2. AWARENESS - A functioning cerebral cortex to determine the content of the consciousness

Question 4

What are some common causes of a patient slipping into a coma state?

Answer 4

• Toxic/metabolic states (hypoxia/liver failure/ketoacidosis)
• Seizures
• Damage to reticular activating system
• Raised ICP

Question 5

Steps when approaching a patient who seems to be in a coma state?

Answer 5

D - check if there’s danger
R - Responsiveness

A - Airways
B - Breathing
C - Circulation
D - Disability

Question 6

Important steps in clinical examination of a patient who has been in a come?

Answer 6

• GCS
• Brainstem function: check cranial nerves & respiratory pattern
• Motor function and reflexes

Question 7

What is meningism?

Answer 7

• Headache, neck stiffness and photophobia

+/- nausea & vomiting

Question 8

If a patient has been in a coma, shows no signs of meningism and no focal cerebral signs, what is the likely cause of the coma?

Answer 8

Toxic / metabolic / systemic issues / Epilepsy

• hypoxia, hypercapnia, sepsis, hypotension
• Drug intoxication, renal / liver failure
• Hypoglycaemia, ketoacidosis

Question 9

If a patient has been in a coma, shows signs of meningism and no focal cerebral signs, what is the likely cause of the coma?

Answer 9

Subarachnoid haemorrhage, Meningitis, Encephalitis

non-focal, raised ICP

Question 10

If a patient has been in a coma, may show signs of meningism and does show focal cerebral signs, what is the likely cause of the coma?

Answer 10

Focal cerebral problem

• eg. Tumour / infarction

Question 11

What is Locked In Syndrome?

Answer 11

Coma like state in which the patient is aware of the situation but is nearly completely paralyzed, with the exception of ability to elevate and depress the eyes, as well as blink

Question 12

Treatment of patients in a coma state?

Answer 12

• Maintain vital functions
• Care of skin / pressure sores
• Bladder / Bowel function
• Control of seizures
• Prophylaxis of DVT, peptic ulceration
• Prevent contractures

Question 13

How does head injury lead to focal neurological signs / epilepsy?

Answer 13

Via:

• Diffuse axonal injury
• Contusion
• Intra / Extra-cerebral haematoma

Question 14

What is the ROSIER scale?

Answer 14

• Means of assessing likelihood of a patient having had a stroke. Ranges from -2 to +5

Score of >0 predicts stroke

Question 15

What is a hemicraniectomy?

Answer 15

Decompressive surgery for stroke patients

Remove bit of skull and open the dura to give space for swollen brain to extend into