8. Examination of the unconscious patient Flashcards
What are three inital things to look for in pt. thought to be unconcious?
- Signs of sleep
- Reaction to external stimulus
- Spontanous activity
GCS features
- Best eye response
- Best verbal response
- Best motor response
High and low GCS score
3 = coma/death
15 = fullt alert and oriented
Pupils and pupillary reactions of unconsciousness
- Unilateral puillary consitricton horners syndrome
- Bilateral pupilaary contstriction = hypthalamus and diencephalon damage
Fixed dilation (no light reflex) = tectum lesions
Anisocoria (1 dilated) = transtentorial herniation
Pinpoint pupils = pontine lesions or opiodes
Gaze disorders of unconsciousness
- Disorder of vertical gaze: damage to nucleus of medial longitudinat fascicle
- Skew deviation: caudal part og brainstem and meso- diencephalon damage
- Random wandering eyes: vegetative phase
- Persisten downward deviation: hepatic encephalopathy/coma
- Persistant upward deviation: global cerebral ischemia
Checking gaze disorders in unconciousness
- Vestibulo-ocular reflex
- Oculocephalic reflex
Oculocephalic reflex (dolls eye)
Turn pt. head to R and L, back and forth, and the eyes will move in opposite direction to stabilize and keep the same image even if the head moves.
- If pupils/eye move with head (fixed), it is a sign of brainstem damage
- If pupils move in opposide direction of movement = intact brainstem
Motor phenomena in unconcious patient
- Motor reactions elicited by painful stimuli
- Decorticate posture (above brainstem)
- Decerebrate posture (below brainstem)
- Unilateral adductor-extensor tone increase ipsilateral thalamus lesions
- Increased flexor tone in legs + flaccid/extensor tone in arms = damage to pons
Neurological examination of comatose patient
- Level of consciousness: GCS
- Pattern of breathing
- Brainstem reflexes
- Motor
- Meningism – nuchal rigidity, headache, photophobia
- Signs of underlying cause
Causes of coma
- Stroke
- Space-occupying lesions
- Meningism = meningoencephalitis or subarachnoid hemorrhage
- Toxins
- Metabolic: “COATPEG” = CO2, O2, ammonia, temp, pH, electrolytes, glucose
- Seizures
Vestibuloocular reflex
Add cold or warm water to ear, check if pupils deviate.
- cold = eyes deviate downward
- warm = upward intact brainstem
This indicates intact brainstem. Nystagmus never seen on comatose patients
Checking motor function comatose patient
- Decorticate = abnormal flexion: lesion above the brainstem
- Decerebrate = abnormal extension: lesion below the brainstem
- Tone
- Reflexes
- Responds to pain: sternal rub, pressing the finger nailbed
