Altered Mental Status/Coma (Pieper)

Question 1

reduced consciousness leading to an acute confusional state characterized by fluctuations in intensity, disorientation, and restlessness or agitation

Answer 1

delirium

Question 2

True or False: coma may be induced with a unilateral or bilateral cortical disturbance.

Answer 2

False! Coma can only be induced under the scenarios of a midline brainstem or bilateral cortical hemisphere disturbance.

Question 3

the reticular formation is located in the midline of the upper pons/midbrain and uses what neurotransmitter to pass signals up the reticular activating system?

Answer 3

acetylcholine (from mesopontine cholinergic cells)

Question 4

The disordered conscious state implies involvment of bilateral or unilateral cortical hemispheres?

Answer 4

Bilateral; it is helpful to think of delirium (a waxing and waning disordered consciousness) as being a milder form of coma. Just as in coma, bilateral cortical involvement is needed to produce symptoms of delirium.

Question 5

True or False: structural causes of bilateral cortical dysfunction are more common than non-structural causes (ie, processes outside the brain that affect its function).

Answer 5

False.

Nonstructural causes of delirium include:

• non-brain organ failure
• vitamin b1 deficiency
• hypo/hyperglycemia
• electrical signaling disruption
• things we ingest
• infection

Question 6

vascular induced insults, infection, tumor and trauma are all forms of ______ causes of hemispheric lesions

Answer 6

structural

Question 7

an abnormal respiration pattern that results from a lesion in the deep hemisphere or diencephalon

Answer 7

cheyne stokes respirations

Question 8

pinpoint pupils point to a lesion where?

Answer 8

pons

Question 9

what VOR sign is seen in patients that are comatose?

Answer 9

with cold water irrigation in the ear canal, they will exhibit tonic eye deviation to the side that of the cold water with NO nystagmus (which is what you would see in a conscious patient)

Question 10

True or False: decorticate posturing is considered better than decerebrate posturing.

Answer 10

True

decorticate = arms and wrists flexed

decerebrate = arms and wrists extended

Question 11

when high ICP occurs acutely, vital sign changes will occur and this is referred to as Cushing’s triad. what signs make up the triad?

Answer 11

hypertension, bradycardia, respiration changes

Question 12

coma with fixed and dilated pupils is evidence of a lesion where?

Answer 12

midbrain

Question 13

this type of herniation is the most serious, as it may compromise the brainstem and cause coma

Answer 13

uncal (infratentorial) herniation

Question 14

All of the following are strategies for the management of increased ICP except:

A. Neuroanesthetics to shut down brain metabolism

B. Corticosteroids to decrease inflammation

C. Craniectomy for more permanent fix of ICP

D. Hyperosmotic therapy with mannitol

E. External ventricular drain (EVD) placement

Answer 14

B. Corticosteroids offer no benefit and increase complication rate.

Question 15

True or False: lowering mean arterial blood pressure in an effort to cause a compensatory decrease in ICP can be attempted after the comatose patient is stabilized.

Answer 15

False. This is a terrible idea. Lowering the blood pressure will cause a drop in the cerebral perfusion pressure, thus worsening ischemia in the already herniated state.

Remember, CPP=MAP-ICP

Question 16

True or False: Coma is a neurological emergency and is commonly structural in etiology.

Answer 16

True