A 8 - Examination of the unconscious patient Flashcards
Observation when examining unconcious patient
1) Semiologic phenomena of sleep (does it look like the patient is sleeping?)
2) Reaction to external stimulus
3) Spontaneous activity
● Glasgow-coma scale for estimation of prognosis (3-coma/death,
15-fully alert and oriented)
● Life-threatening circulatory or respiratory disorders should be
excluded/treated before neurological exam.
● Check for signs of external trauma on the skull
● Observe eye position, brainstem reflexes (incl. pupillary reflex), position and muscle tone
● Apply painful stim., note elicited motor reactions
● Examine deep tendon and superficial reflexes and pyramidal
signs
Signs and symptoms of an unconscious patient
Ocular symptoms
Vestibular reactions
Motor phenomena
Signs and symptoms of an unconscious patient:
Ocular symptoms
Pupils and pupillary reactions
Gaze disorders
What are the Pupils and pupillary reactions?
● Pupillary constriction
● Pupillary dilation
● Fixed, moderately dilated pupils
● Anisocoria
● Pinpoint pupils
What is papillary constriction?
It is light reactions are preserved!
○ Bilateral → bilateral hypothalamus and diencephalon damage
○ Horner’s syndrome (miosis, ptosis, anhidrosis) → unilateral damage
What is Pupillary dilation?
NO pupillary light reactions, hippus may be seen → tectum lesions
Fixed, moderately dilated pupils indicate
lesion below tectum
what is Anisocoria
pupil on the side of oculomotor n. compression is larger → transtentorial herniation
what is Pinpoint pupils
pontine lesions disrupting descending SY fibers
What are the Gaze disorders?
Disorder of vertical gaze
Skew deviation
Randomly wandering eyes
Persistent upward deviation
Persistent downward deviation
Bell’s phenomenon
what are the disorder of vertical gaze?
downward rotation → damage to rostral interstitial nucleus of medial longitudinal fascicle
what is skew deviation?
eyes diverge in vertical direction, one rotated down, the other up → caudal part of brainstem and meso-diencephalon damage
what does Randomly wandering eyes indicate?
persistent vegetative phase
what does Persistent upward deviation indicates?
global cerebral ischemia
what is Bell’s phenomenon?
reflex upward movement of the eye when closed may be elicited in a somnolent patient if tegmentum and CNIII are intact
what are the Vestibular reactions?
- Vestibulo-ocular (doll’s eye) reflex
- Reaction to stimulation w/ cold water into ear
what is Vestibulo-ocular (doll’s eye) reflex?
elicited by turning the pt. head to the R and L, back and forward → eyes will move conjugately in opposite direction
● If they move together with the head (fixed) → brainstem damage
descirbe the Reaction to stimulation w/ cold water into ear?
● Regular nystagmus w/ a quick and slow component, beating towards contralat. ear
● Conjugate deviation towards stim. ear w/ only a few nystagmoid jerks towards contralat. ear
● Conjugate deviation towards stim. ear, but no quick component
● The eyes don’t move at all → severe brain stem injury
What the Motor phenomena includes?
- Motor reactions elicited by painful stimuli
- Possible findings
in the motor phenomena, what Motor reactions elicited by painful stimuli may be?
● Appropriate, coordinated withdrawal
● Inappropriate movements
● Abnormal increase of muscle tone
in the motor phenomena, what are the pissible findings?
● Decorticate posture (flexion of arms and extension of legs, increasing w/ painful stim.) → bilat. diencephalic lesion
● Unilat. adductor-extensor tone increase → ipsilat. thalamus lesion
● Decerebrate posture (increased extensor-adductor tone in all limbs, increased adductor-torsional tone w/ painful stim.) → mesencephalon damage
● Increased flexor tone in legs, flaccid/increased extensor tone in arms → damage to pons
