Coma

1. Differentiate Among Coma, Unresponsive Wakefulness & Minimally Conscious States

  • Coma: A state of profound unconsciousness, where the patient is not awake and not aware. There is no spontaneous eye-opening, purposeful movement, or speech, and no evidence of a sleep-wake cycle on EEG. It is commonly seen in severe TBI (Glasgow Coma Scale <8)​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

  • Unresponsive Wakefulness (Vegetative State): The individual is awake (spontaneous eye-opening) but unaware of the environment. They do not follow commands or visually track, and brainstem functions like respiration and digestion are preserved​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

  • Minimally Conscious State (MCS): The patient is awake with emerging awareness. They may show inconsistent responses, such as following commands or visual tracking, and can demonstrate purposeful behavior​(Cog(21) Coma handout FI…).

2. Identify 3 Determinants of TBI Severity (and Associated LOC, GCS, and PTA Scores)

  • Loss of Consciousness (LOC):

    • Mild TBI: LOC <30 minutes.

    • Moderate TBI: LOC 30 minutes to 24 hours.

    • Severe TBI: LOC >24 hours​(Cog 24 Coma).

  • Glasgow Coma Scale (GCS):

    • Mild TBI: GCS 13-15.

    • Moderate TBI: GCS 9-12.

    • Severe TBI: GCS ≤8​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

  • Post-Traumatic Amnesia (PTA):

    • Mild TBI: PTA <24 hours.

    • Moderate TBI: PTA 1-7 days.

    • Severe TBI: PTA >7 days​(Cog(21) Coma handout FI…).

3. Discuss the Glasgow Coma Scale (GCS)

  • Components: Eye opening (E), motor response (M), and verbal response (V).

  • Use: Commonly used to assess the level of consciousness after a brain injury.

  • Findings: Scores range from 3 to 15, with a score of ≤8 indicating coma and higher scores reflecting better neurological function​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

  • Strengths: Quick, widely accepted, and used in various settings​(Cog 24 Coma).

  • Limitations: Limited usefulness in intubated patients and young children, and it does not account for certain cognitive aspects​(Cog(21) Coma handout FI…).

4. Differentiate Between Decerebrate & Decorticate Posturing

  • Decerebrate Posturing: Characterized by extension of the arms and legs, indicating brainstem damage​(Cog 24 Coma).

  • Decorticate Posturing: Flexion of the arms and wrists with extension of the legs, indicating damage to the cerebral hemispheres​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

5. Calculate, Interpret, and Document the GCS Score for a Client

Given a scenario where a patient:

  • Opens eyes to sound (E3),

  • Withdraws from painful stimuli (M4),

  • Responds with inappropriate words (V3), The GCS score would be E3 + M4 + V3 = 10, indicating moderate brain injury​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

6. Differentiate Between Post-Traumatic Amnesia (PTA) and Retrograde Amnesia

  • Post-Traumatic Amnesia (PTA): Inability to form new memories after the injury, associated with the severity of the TBI​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

  • Retrograde Amnesia: Loss of memories that were formed before the injury​(Cog(21) Coma handout FI…).

7. Describe Use and Administer/Interpret Results of the Galveston Orientation & Amnesia Test (GOAT)

The GOAT assesses orientation and memory in TBI patients. A score of 76 or above on 3 consecutive occasions indicates the resolution of PTA. It evaluates the patient's memory of pre-injury and post-injury events​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

8. Describe OT Evaluation and Intervention Methods for Patients in a Coma or Altered State (Rancho I, II, III)

  • Rancho I (No response): OT interventions include preventing complications (e.g., positioning, PROM)​(Cog(21) Coma handout FI…).

  • Rancho II (Generalized response): Sensory stimulation to provoke generalized movements​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

  • Rancho III (Localized response): Use structured sensory stimulation and simple tasks​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

9. Differentiate Behaviors Exhibited by Individuals in Rancho Level I, II, and III

  • Rancho I: No response to stimuli​(Cog(21) Coma handout FI…).

  • Rancho II: Generalized reflexive responses, such as delayed movements​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

  • Rancho III: Localized responses, such as withdrawal from pain or eye movement towards sounds​(Cog(21) Coma handout FI…).

10. Recognize Coma Assessments by Name Based on a Picture

Familiarize yourself with the layout and components of assessments such as the Glasgow Coma Scale, Coma Recovery Scale, and Ranchos Los Amigos scale​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

11. Describe the Role of the Occupational Therapist in Coma Recovery

OTs support recovery by:

  • Preventing secondary complications (e.g., splinting, positioning),

  • Sensory stimulation,

  • Family education, and

  • Continuously evaluating the patient to plan for discharge​(Cog 24 Coma)​(Cog(21) Coma handout FI…).

12. Write Occupational Therapy Goals for Patients in Coma, Vegetative State, and MCS

  • Coma: "Patient will respond to tactile stimulation with increased muscle tone within 2 weeks."

  • Vegetative State: "Patient will open eyes in response to auditory stimuli in 50% of trials."

  • Minimally Conscious State: "Patient will follow one-step commands in 2 out of 5 trials"​(Cog(21) Coma handout FI…)​(Cog 24 Coma).