30.2 📚 國考版醫垫國考 / PGY OSCE

30.2.0.1 📌 Cram Sheet

30.2.0.1.1 🔥 高 yield 10 條
  1. 意識 = arousal (ARAS) + awareness (cortex)
  2. Coma 機蜉 = bilateral hemisphere OR brainstem ARAS dysfunction
  3. GCS E4V5M6 必背
  4. GCS ≀ 8 = intubate
  5. Coma cocktail: glucose / thiamine / naloxone / flumazenil
  6. Thiamine BEFORE glucose in alcoholic
  7. Pinpoint pupil = pons / opioid
  8. Fixed dilated unilateral = CN III / uncal herniation
  9. Decorticate vs Decerebrate埌者范差
  10. Locked-in syndrome ≠ coma病人 aware
30.2.0.1.2 🔢 必背
項目 æ•žå­—
GCS range 3-15
GCS intubate threshold ≀ 8
GCS mild TBI 13-15
GCS moderate 9-12
GCS severe 3-8
Glucose IV dose D50 50 mL or D10 200 mL
Naloxone dose 0.04-2 mg IV q2-3 min
Thiamine dose 100-500 mg IV
Cushing’s reflex (↑ICP) HTN + bradycardia + irregular respiration
30.2.0.1.3 ⚠ 陷阱
  • 䞍查 glucose
  • Opioid OD 䞍 naloxone
  • Glucose before thiamine
  • GCS ≀ 8 䞍 intubate
  • Locked-in 當 coma

30.2.0.2 ⭐ 高 yield

30.2.0.2.1 GCS Component
Score Description
Eye 4 自癌
3 喊
2 痛
1 無
Verbal 5 oriented
4 confused
3 䞍當字
2 聲音
1 無
Motor 6 obey
5 localize
4 withdraw
3 decorticate
2 decerebrate
1 無
30.2.0.2.2 Brainstem Reflex Localization
Reflex äž­æšž
Pupillary light Midbrain
Corneal Pons
Oculocephalic Pons / Midbrain
Cold caloric Brainstem
Gag Medulla
30.2.0.2.3 Pupil Patterns
Pupil 病因
Pinpoint reactive Pons / Opioid
Mid-fixed Midbrain
Dilated unilateral fixed CN III / Uncal herniation
Dilated bilateral fixed Severe brain injury / Anoxic / Atropine
30.2.0.2.4 AEIOU TIPS病因蚘憶
  • A: Alcohol/Acid-base/Anemia
  • E: Electrolyte/Endocrine
  • I: Insulin (hypo/hyper)
  • O: Oxygen/Opioid/Overdose
  • U: Uremia
  • T: Trauma/Temperature
  • I: Infection
  • P: Psychiatric/Poisoning
  • S: Seizure/Stroke/Shock
30.2.0.2.5 Coma Mimics
特埵
Locked-in Pons ventral lesion意識枅只胜眚県 + 垂盎県動
Persistent vegetative state 沒 awareness䜆有 sleep/wake cycle
Minimally conscious state 郚分 awareness
Brain death 無 brainstem reflex + apnea test + 䞍可逆
Catatonia Psychiatric, 可胜仍 aware
Akinetic mutism Frontal/cingulate lesion
30.2.0.2.6 Brain Death Criteria
  • Coma + 可逆原因排陀
  • Absent brainstem reflexes (pupil, corneal, oculocephalic, cold caloric, gag/cough)
  • Apnea test +PaCO2 ≥ 60 mmHg or 20 ↑ from baseline 無 respiratory effort
  • 重耇確認 (時間間隔䟝各國)
30.2.0.2.7 Herniation
Type 特埵
Uncal Ipsi pupil fixed dilated + contralateral hemi
Central Rostro-caudal progression
Tonsillar Respiratory arrest
Subfalcine ACA 壓迫

30.2.0.3 🎯 自我檢枬

  1. GCS ≀ 8? → Intubate
  2. 意識 2 components? → Arousal (ARAS) + awareness (cortex)
  3. Pinpoint pupil 兩個原因? → Pons lesion / opioid
  4. Uncal herniation pupil? → Ipsilateral fixed dilated
  5. Coma cocktail 4 元玠? → Glucose / thiamine / naloxone / flumazenil
  6. Alcoholic 絊 glucose 之前? → Thiamine
  7. Decerebrate posturing 哪個動䜜? → 四肢 extend
  8. Brain death pCO2 threshold? → ≥ 60
  9. Cushing’s reflex? → HTN + bradycardia + irregular respiration↑ICP
  10. Locked-in 哪裡受損? → Ventral pons

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