ALTERED MENTAL STATUS

Question 1

(1) Level of consciousness is depressed.
(2) Stuporous patients respond only to repeated vigorous stimuli.
(3) Comatose patients are unarousable and unresponsive.
(4) Coma is a major complication of serious central nervous system disorders

Answer 1

Altered Mental Status:
Essentials of Diagnosis

Question 2

(a) Seizures,
(b) Hypothermia,
(c) Metabolic disturbances,
(d) Structural lesions causing bilateral cerebral hemispheric dysfunction or
(e) A disturbance of the brainstem reticular activating system.
(f) A mass lesion involving one cerebral hemisphere may cause coma by compression
of the brainstem.

Answer 2

Coma is a major complication of serious central nervous system disorders. It can result
from:

Question 3

In hypothermia, all vital signs may be absent, and all such patients should be

Answer 3

rewarmed before the prognosis is assessed.

Question 4

The patient can be positioned on one side with the neck partly extended, dentures removed, and secretions cleared by suction; if necessary, the patency of the airways is maintained with an

Answer 4

oropharyngeal airway.

Question 5

(a) Subarachnoid hemorrhage,
(b) Brainstem stroke,
(c) Intracerebral hemorrhage,
(d) Whereas a slower onset and progression occur with other structural or mass lesions.

Answer 5

Abrupt onset of coma could suggest

Question 6

Urgent non-contrast CT scanning recommended for

Answer 6

of the head is appropriate if it can be obtained
directly from the emergency department, in order to identify intracranial hemorrhage, brain herniation, or other structural lesion that may require immediate neurosurgical intervention.

Question 7

What cause is likely with a preceding intoxicated state or agitated delirium.

Answer 7

metabolic

Question 8

Purposeful limb withdrawal from painful stimuli implies that sensory pathways from and motor pathways to the stimulated limb are functionally intact.

Answer 8

Response to Painful Stimuli

Question 9

responses despite application of stimuli to both sides of the body in turn implies a corticospinal lesion

Answer 9

Unilateral absence of responses

Question 10

responsiveness suggests brainstem involvement, bilateral pyramidal tract lesions, or psychogenic unresponsiveness

Answer 10

Bilateral absence of responsiveness

Question 11

posturing may occur with lesions of the internal capsule and rostral cerebral peduncle and decerebrate (extensor) posturing

Answer 11

Altered Mental Status: Decorticate (flexor)

Question 12

posturing occurs in the arms accompanied by flaccidity or slight flexor responses in the legs in patients

Answer 12

Altered Mental Status: Decerebrate

Question 13

a) The pupils are slightly smaller than normal but responsive to light
b) Dilated pupils (mydriasis) could suggest brainstem compression, drug overdose on MDMA, cocaine, amphetamines
c) Constricted pupils (miosis) HA could suggest drug overdose with opiates/opioids

Answer 13

Ocular Findings: Pupil

Question 14

a) Touching the cornea with a wisp of sterile gauze or cotton should elicit a blink reflex.
b)*** The afferent limb of the arc is mediated by the fifth cranial nerve; the efferent limb by the seventh nerve.
c) A unilateral absent corneal reflex implies damage to the ipsilateral pons or a trigeminal deficit.
d) Bilateral loss can be seen with large pontine lesions

Answer 14

Ocular Findings: Corneal reflex

Question 15

Conjugate deviation of the eyes to the side suggests the presence of an ipsilateral hemispheric lesion

Answer 15

Ocular Findings: Eye movements

Question 16

Diseases causing coma may lead to respiratory abnormalities.
2) Cheyne-Stokes respiration (in which episodes of deep breathing alternate with periods of apnea)

3) Central neurogenic hyperventilation occurs with lesions of the brainstem tegmentum.

4) Apneustic breathing (in which there are prominent end-inspiratory pauses) suggests damage at the pontine level (e.g., due to basilar artery occlusion).

5) Atactic breathing (a completely irregular pattern of breathing with deep and shallow breaths occurring randomly) is associated with lesions of the lower
pontine tegmentum and medulla.

Answer 16

Altered Mental Status: Respiratory Patterns

Question 17

Maximum score of 15, Minimum score of 3

Answer 17

Glasgow Coma Scale

Question 18

Intubate; Glasgow Coma Scale

Answer 18

Less than 8,
Note: If intubated verbal response graded “1T”

Question 19

(1) Depends on the cause and hemodynamic stability
(2) If not quickly reversible then MEDEVAC
(3) Reversal for Opioids is
(a) Naloxone (Narcan)- opioid antagonist
4) Contraindications: None
5) Monitoring of the patient is essential, as the half-life of Naloxone is short compared to longer-acting opioids (Methadone) so repeated dosing may be
required to prevent return of sedation and respiratory compromise.

Answer 19

Altered Mental Status: Treatment