Coma-2 - Evaluation of Patients in Coma Liam Durcan MD...

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Evaluation of Patients in Coma Liam Durcan MD FRCPC Department of Neurology and Neurosurgery
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What We’ll Cover Basic definitions Key  exam points Epidemiology of Coma Coma mimics
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What we won’t talk about Brain death/ chronic vegetative state toxidromes really complex neuroanatomy Exhaustive lists of causes Basic Resuscitative Care
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Definitions Coma: “Unarousable unresponsiveness in  which the subjects lie with eyes closed” Plum and Posner- Diagnosis of Stupor and  Coma Other terms: obtundation, stupor fallen out of favour because of imprecision descriptive methods favoured
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Consciousness Two components of conscious behavior content- the sum of cognitive and affective  function arousal- appearance of wakefulness Content depends on arousal but normal  arousal does not guarantee normal  content
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Really Simple Neuroanatomy Arousal: where is it localized? Ascending Reticular Activating System  (ARAS) ‘core of the brainstem’ receives input from numerous somatic  afferents projects to midline thalamic nuclei (which are  in a circuit with cortical structures) and the   limbic system
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ARAS ARAS acts as a gating system, increasing  or decreasing thalamic inhibitory influence  on the cortex alters effect of sensory stimuli ascending alters descending cortical stimulation 
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Demands of Arousal Function of ARAS-Thalamic-Cortical  system depends on: anatomic integrity of structures metabolic integrity (circulatory integrity) communicative integrity (neurotransmitter  function)
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Coma Fact Number One Coma implies dysfunction of: ARAS  or Both  hemi-cortices Anatomically, this means central brainstem structures (bilaterally) from  caudal medulla to rostral midbrain both hemispheres
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