3. Clinical Approach to Stupor and Coma

Question 1

What is total awareness of self and environment which requires arousal-level of alertness/ability to interact with environment and awareness (content)- sum of cognitive mental functions to know what’s going on?

Answer 1

Consciousness

Question 2

Consciousness depends on arousal of cerebral cortex by the brainstem ascending reticular activating system (ARAS)- receives input from many sensory systems and projects to hypothalamus, thalamus and?

Answer 2

Cortex

Question 3

What means that there is diffuse bilateral impairment of both cerebral hemispheres or there is failure of brainstem ARAS or both?

Answer 3

Impaired Consciousness

Question 4

Confusion is assoc with attention deficit, orientation disturbed and stimuli misinterpreted… What is assoc with disorientation, stimuli misinterpreted and with visual hallucinations?

Answer 4

Delirium

Question 5

Stupor is a state of altered consciousness associated with arousing only to noxious stimuli and not environmental, only rudimentary awareness (purposeful motor responses), what is associated with not being able to be aroused, unresponsive and unaware?

Answer 5

Coma

*Note: a pt may pass through any or all of these states on the way to or out of a coma

Question 6

History * is important in assesment of a comatose patient, received from family, EMTs and witnesses, ask how and when patient was found, sudden or gradual onset**, prior illnesses, recent symptoms and history of?

Answer 6

Substance abuse

Question 7

After history, general examination is performed such as vital signs, skin, breath odor, signs of trauma including racoon eyes, battle’s sign (bruising indicating fracture at bottom of skull), CSF leak (rhinorrhea), and what can be check for meningismus/meningitis and subarachnoid hemorrhage?

Answer 7

Neck stiffness- flex neck and if pain = + sign

Question 8

After general assessment move onto neurological examination whose purpose is two fold, 1) to determine the location and nature of the process that is causing the impaired consciousness with emphasis on the anatomic level of brain involvement (supratentorial/subtentorial/diffuse) and 2) to narrow?

Answer 8

the differential possibilities

Question 9

Theres a broad category of lesions that produce comas; large, pressure producing supratentorial mass lesions (cortical) which cause dysfunction in upper ARAS and cause downward herniation of the brain to compress the ARAS, diffuse or multifocal brain disease, and what lesions that involve the brainstem- causing brainstem signs?

Answer 9

Intratentorial mass lesions

Question 10

Supratentorial causes of stupor and coma- unilateral hemisphere or mass effect causes include intracerebral hemorrhage, large MCA infarct, neoplasm, brain abscess, epidural hematoma, and what which is more common?

Answer 10

Subdural Hematoma

Question 11

Bilateral hemisphere supratentorial causes of coma include subarachnoid hemorrhage, multiple infarcts, venous thrombosis, acute hydrocephalus, metastases and?*

Answer 11

Cerebral Edema

Question 12

Subtentorial causes of coma include pontine hemorrhage, basilar artery occlusion, central pontine myelinolysis, cerebellar/brainstem neoplasm, cerebellar abscess and most importantly/dangerous is?

Answer 12

Cerebellar hemorrhage/infarct

Question 13

Diffuse causes of coma and stupor include vasculitis, hypoxia, hypercapnia, infections- meningitis/encephalitis, acute hypthyroidism, hypercalcemia, drug intoxication or withdrawal, seizures and what two metabolic ones are important?

Answer 13

Hypo/Hyperglycemia

Question 14

neurological examination essential elements include pupillary responses, corneal reflex, extraocular movements, cough/gag reflex, motor responses and respiratory pattern, other nearly essential elements include neck stiffness, carotid auscultation (not anymore) and importantly?

Answer 14

Funduscopic examination (view entire retina to see papilledema/cotton wool spots/infarcts)

Question 15

Pupillary Reflex - shine light
Afferent:
Efferent:

Answer 15

Afferent: CN2
Efferent: CN3 dilation

Question 16

Corneal Reflex - scratch cornea with Qtip
Afferent:
Efferent:

Answer 16

Afferent: CN5
Efferent: CNVII (close eye via eyelid M)

Question 17

Cold Water Irrigation
Afferent:
Efferent:

Answer 17

Afferent: CN VIII
Efferent: CN 3/6

Question 18

Gag Reflex (tug on tube in throat)
Afferent:
Efferent:

Answer 18

Afferent: CN IX (9)
Efferent: CN X (10) gags

Question 19

Press Supraorbital N.
Afferent:
Efferent:

Answer 19

Afferent: CN V
Efferent: CN VII - Grimace*

Question 20

The sympathetic path for pupillary responses include: hypothalamus to lower cervical cord (1st order neuron) to sympathetic chain (2nd order), to superior cervical ganglion, to upper carotid A to CN V(I), long ciliary nerve (dilator) to mueller’s muscle. Parasymp path is upper midbrain (edinger westfall nuc) to CN III to ciliary ganglion to short ciliary N. (pupillary constrictor)… The tracts controlling pupils are adjacent to ARAS to absent or unequal responses implies?

Answer 20

A brainstem lesion!

Question 21

Rule of thumb for abnormal pupils (anisocoria= unequal size of pupils): if its the large pupil it should fail to constrict to light, if its the small pupil it should fail to?

Answer 21

Dilate in the dark

Question 22

Pupillary Responses: if enlarged on one side: PNS dysfunction (CNIII), if enlarged bilaterally: bilat CNIII lesion (seen post seizure/intoxications), if both constricted= sympathetic dysfunction as seen in carotid and?

Answer 22

Hypothalamus

Question 23

Pupillary Responses: if midposition and unreactive- sympathetic + parasympathetic = midbrain issue, if pinpoint it is commonly due to the three P’s including oPiates, Pilocarpine for glaucoma and?

Answer 23

Pontine lesion

Question 24

Interpretation of pupillary signs may be confused by atropine/scopalomine causing dilated and fixed pupils, by opiates = pinpoint +/- reactive, pilocarpine - pinpoint, and hypothermia/anoxia/ischemia which causes the pupils to be dilated, fixed and?

Answer 24

Unequal

Fundoscopy is used to check for papilledema caused by ICP

Question 25

Extraocular movements- conjugate gaze depends on intact cranial nerves III, IV, and VI, their nuclei and interconnections, pontine gaze centers when lesioned deviates the eyes to the SAME side and what gaze centers when lesioned, deviates eyes to the OPPOSITE side?

Answer 25

Frontal Gaze Centers

Question 26

Spontaneous extraocular movements: Roving eye movements are slow, conjugate, lateral, to and fro excursions. These occur when third nerve nuclei and connections are intact and often indicate a toxic, metabolic or alternatively bilateral hemisphere cause for coma… Conjugate roving= implies brainstem intact, dysconjugate roving implies?

Answer 26

Brainstem lesion

Question 27

If there is conjugate deviation at rest (also seen in oculocephalic reflex) if there is a hemispheric lesion: destructive= toward lesion and irritative = away from lesion. if its a brainstem lesion- destructive will have conjugate deviation at rest being?

Answer 27

Away from the lesion- opposite of a hemispheric lesion

Question 28

There are many types of nystagmus including ping pong which is right-left deviation every few seconds= lesion in bihemispheric or midbrain, convergence (slow abduction with rapid jerk back) = mesencephalon, retractory (retraction orbit) = mesencephalon, bobbing (rapid down, slow up) = pons and dipping (slow down, rapid up) = lesion where?

Answer 28

Bihemispheric

Question 29

what is a reflexive extraocular movement, in which the neck should be stable without fracture, and must be done in an unconscious patient, used to asses mid pons/ CNIII , IV, VI, with passive horizontal head rotation eyes should move horizontally opposite, and with passive vertical head rotation- eyes shoulw move vertically opposite?

Answer 29

Oculocephalix Maneuver = Doll’s Eyes

Question 30

What is a reflexive extraocular movement to test the lower pons, first check ear to make sure canal clear and TM intact, irrigate TM with cold water, if brain stem is INTACT it causes the eyes to deviate TOWARDS irrigated side, if doing unilateral irrigation, if doing bilateral irrigation eyes deviate DOWNWARD?

Answer 30

Caloric (oculovestibular) reflex = Cold water irrigation in an unconscious patient

Question 31

Motor responses during the neuro exam has two sections- purposeful which is where u pinch/ try to arouse to see if follow commands or can localized pain, second section is reflexive which in a coma patient is seen as decorticate or decerebrate, what is the difference?

Answer 31

Decorticate: arms flexed, legs extended = hemispheric
Decerebrate: all extrem extended = brainstem

(flaccid = pontomedullary or toxic metabolic issue)

Question 32

What respiratory pattern during neuro exam is hyperpnia regularly alternating with apnea- crescendo-decrescendo breathing pattern followed by apnea or hypopnea-persists in sleep, lesion at bilat/unilateral bihemispheric or diencephalon?

Answer 32

Cheynes-Stokes

Question 33

Another respiratory pattern during neuro exam is central neurogenic hyperventilation caused by a lesion in midbrain, ataxic respiratory lesion is completely irregular caused by a lesion in medullary respiratory center and what breathing is long inspiration followed by apnea seen in structural lesions and anoxia, hypoglycemia and meningitis, lesion in mid/low pons?

Answer 33

Apneustic Breathing

Question 34

Supratentorial mass lesions that cause coma and stupor have initial signs that are focal, neuro signs at any given time point to ONE anatomic location, motor signs are often Asymmetric and progression of signs is ?

Answer 34

Rostral to Caudal

Question 35

Herniation syndromes are caused by expanding supratentorial mass lesions, effect is to displace brain tissue into adjacent intracranial compartments. What is the MC type of transtentorial herniation in which it is herniated under the tentorium compressing CNIII (ipsi dilated pupil, poor EOM, ptosis) and the contralateral brainstem (ipsi hemiparesis) then resp abnls, posturing, fixed pupils and death?

Answer 35

Uncal Transtentorial herniation

*Eye will be DOWN AND OUT

Question 36

The cingulate gyrus may herniate under the falx. What herniation herniates into foramen magnum leading to coma, small pupils, normal EOMs, posturing, and later bilateral fixed pupils, resp arrest and death?

Answer 36

Central transtentorial

Question 37

What mass lesions have a history of preceding brainstem dysfunction (6D’s= dysequilibrium, dysarthria, dysphagia, diplopia, vertigo) with sudden onset coma, almost always includes a form of oculovestibular abnl, cranial nerve palsies and bizarre respiratory patterns are usually present?

Answer 37

Subtentorial Mass Lesions - Least common

Question 38

What cause of coma has confusion and stupor that commonly precedes motor signs, motor signs are SYMmetrical, pupillary reactions usually *preserved, asterixis, myoclonus, tremor, seizures are common, acidbase imbalance with hyper/hypoventilation seen, level of consciousness may fluctuate?

Answer 38

Diffuse/Metabolic cause of coma

such as hepatic/renal fail, hyper/hypoglyc, hypoxia*, sepsis, infections, drugs and toxins

Question 39

What occurs whenever blood flow is inadequate to meet the metabolic requirements (oxygen/glucose) of the brain as in cardiac or pulmonary arrest, resulting in a spectrum of disorders ranging from reversible encephalopathies to brain death?

Answer 39

Global Cerebral Ischemia

Question 40

What type of global cerebral ischemia are commonly reversible, generally after 12 hours or less of stupor/coma, antero/retrograde amnesia may occur, with recovery occuring in 7-10 days but possibly being delayed 1month +?

Answer 40

Brief (<6 mins) ischemic episodes

Question 41

What type of global cerebral ischemia have focal cerebral dysfunction- patients are usually comatose for 12 hours and may have lasting focal or multifocal motor, sensory and cognitive deficits?

Answer 41

Prolonged Ischemic Episode

Question 42

What type of global cerebral ischemia is when the patient is awake but functionally decorticate and unaware of surroundings- eye opening, eye movements, sleep wake cycles and brainstem and spinal reflexes may remain intact?

Answer 42

Persistent Vegetative State

Question 43

What definition implies irreversibility, persistence and complete cessation of brain function (including respirations but NOT heart beat)?

Answer 43

Brain Death

Question 44

Brain death irreversibility should only be used if the cause of the coma is known, it must be adequate to explain the clinical picture and must be irreversible- some things that immitate this is sedative intoxication, hypothermia, NM blockage, and what?

Answer 44

SHOCK

Question 45

Cessation of brain function means there is unresponsiveness- the patient must be unresponsive to all sensory input including pain/speech, there are ABSENT brainstem reflexes including pupillary, corneal, oculocephalic, and oculovestibular, *resp responses are absent at 8-10 mins after pts pCO2 is risen to 60mmHg while oxygenation is maintatined with?

Answer 45

100% O2

Question 46

The following steps are part of what test?

1. Check if core temp >36.5C/BP>90, Fluid balance pos
2. Preoxygenate for 10min, dec ventilation to 10breath/min, PO2 >200, PCO2.40
3. Disconnect Ventilator
4. Monitor for chest wall/abd wall movement
5. No resp movement for 8min, if PCO2 >60 or increases more than 20mmHg
6. Reconnect Ventilator = document BRAIN DEATH

Answer 46

Apnea Test

Question 47

Criteria for brain death must persist for an appropriate amount of time- 6 hours with flat/isoelectric EEG, 12 hours without confirmatory isoelectric EEG, 24 hours for anoxic brain injury without a?

Answer 47

confirmatory isoelectric EEG

Question 48

Management of a comatose patient… ABC’s
A: insure patent Airways
B: insure Breathing and adequate oxygenation
C: ?

Answer 48

Insure adequate Circulation and control any active bleeding

stabilize neck & cspine xray if trauma expected

Question 49

Management of a comatose patient after ABCs.. quick history, general exam, EKG to monitor for arrythmias, give glucose, or any specific antidote (narcan), adjust body temp, control agitation and stop what if present?

Answer 49

Seizures

Question 50

For a coma person, get glucose/electrolytes/BUN, creatinine, osmolality, drug screen, liver functions, ammonia, coagulation, studies, thyroid function, blood cultures (CMP) from venous blood, get pH, pO2, pCO2, HCO3 and HbCO from arterial blood, urine culture/UA/drug screen, if stiff neck do a LP after CT w CSF for cell count, glucose, protein, gram stain and cultures, if febrile what should be done?

Answer 50

Blood cultures +/- CSF cultures

Question 51

Diagnostic testing for a comatose patient includes noncontrast head CT to check for acute blood or space occupying lesion, lumbar puncture LP for xanothochromia (SAH) and infection, +/- MRI for posterior fossa in early infant, +/- EEG, treat seizures with either phenytoin or?

Answer 51

Lorazepam

Question 52

What should be reduced, which can be reduced via elevating head of bed, intubate and hyperventilate to pCO2 of 20mm, use mannitol/hypertonic saline for ischemic lesions, using decadron for tumor, abscess, and cerebral hemorrhage and Lasix 20-40mg IV possibly?

Answer 52

Reducing elevated intracranial pressure

Question 53

What coma scale gives you a number between 3-15, 3 being bad and 15 being good based on eye opening, best verbal response, and best motor response?

Answer 53

Glasgow Coma Scale