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2011-07-16 23:42:33
clin path

clin path 4
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  1. 3 descriptors of coma
    • sleep-like state from which pt can't be aroused
    • unresponsive to ext stimuli/int needs
    • reflex responses may be present
  2. Levels of consciousness
    • alert
    • lethargic: drowsy, may fall asleep
    • delirium: disorientation, confusion
    • obtunded: dec alertness, requires repeated stimulus to maintain consciousness
    • stupor: conscious, but little or no spontaneous activity; only responds to strong noxious stimuli
    • coma
  3. Sudden onset
    suggest vascular origin (brainstem or subarachnoid hemorrhage)
  4. rapid progression
    suggests intracerebral hemorrhage
  5. slow progression
    suggests tumor, abscess, or chronic subdural hematoma
  6. coma preceded by confusional state
    suggests metabolic imbalance
  7. Responsive pupils
    pupils of both eyes constrict quickly and symmetrically
  8. fixed dilated pupils
    nonreactive to light; suggests CN III lesion
  9. fixed midsize pupils
    suggest midbrain lesion
  10. pinpoint pupils
    suggests pontine lesion
  11. asymmetric pupils
    suggests lesion to midbrain or CN III
  12. Doll's head maneuver
    assess oculomotor response to head movement
  13. caloric test
    ice water poured into ear, normal response is nystagmus w/ fast phase to opposite sd; assess vestibulo-ocular response
  14. Locked in syndrome
    • NOT a coma
    • pontine infarction or other transection of brainstem below midbrain
    • pt mute and quadriplegic but *preserved voluntary eye movements
  15. Diffuse encephalopathy
    • reactive pupils but other brainstem functions impaired
    • can be caused by hypoglycemia, electrolyte imbalance, meningitis, subarachnoid hemorrhage, ischemia, hypo/hyperthermia
  16. Better prognosis if:
    • younger age
    • responsive pupils during first 24 hours
    • normal response to caloric test in 24 hours
    • signs of brainstem function
    • higher GCS in first 24 hours
    • shorter duration
    • intensive rehab started earlier
  17. Role of PTs in coma
    • positioning/movement for prevention of pressure sores
    • ROM for prevention of contractures
    • vestibular stimulation and cardiovascular responses to movement
    • interact as if pt conscious
  18. Coma stimulation
    • aimed at inc arousal
    • inc auditory, visual, tactile, gustatory, olfactory, kinesthetic stimuli
    • inc pt's purposeful responses
    • pt needs to have stable vital signs before can begin and ICP below 15
    • best to have quiet environment to promote selective attention