CC5: Coma Flashcards

1
Q

List the 7 exams to do during a COMA examination

A
1 - Neurological Exam of Altered Consciousness
2 - Vital Signs
3 - Respiratory Pattern
4 - Level of Consciousness
5 - Pupils
6 - Ocular movements
7 - Motor Responses
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2
Q

There is a Neurological Exam of Altered Consciousness. What are the 4 levels of consciousness?

A

1 - Normal - no external stimulation needed to be awake

2 - Somnolent -external stimulation will lead to normal wakefulness

3 - Obtunded -external stimulation will not lead to normal wakefulness

4 - Coma -No wakefulness

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3
Q

We talked about 3 respiratory patterns. Describe them and state where the lesion may be.

A

1 - Cheyne-stokes respiration: abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea. Lesion in diencephelon

2 - Central neurogenic hyperventilation: abnormal pattern of breathing characterized by deep and rapid breaths at a rate of at least 25 breaths per minute. Increasing irregularity of this respiratory rate generally is a sign that the patient will enter into coma. Lesion in midbrain, but lower center in pons is working which is responsible for producing the deep breaths at regular pace.

3 - Apneustic respirations: abnormal pattern of breathing characterized by deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release. Lesion in pons, but medulla is still working.

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4
Q

What effect will a lesion caused by metabolic problems (due to drugs) have on the pupils?

A

The pupils will be small, but reactive to light.

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5
Q

What effect will a lesion in diencephelon have on pupils?

A

The pupils will be small, but reactive to light.

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6
Q

What effect will ioslated lesion in the tectum (superior and inferior colliculi in midbrain) have on pupils?

A

The pupils will be in mid-position, and not reactive to light.

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7
Q

What effect will lesion of the CN III have on pupils?

A

There will be no direct pupillary light reflex, but there will be a consensual response.

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8
Q

What effect will lesion in the midbrain have on pupils?

A

midposition, no pupillary light response.

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9
Q

If someone has big pupils, and no coma, it may suggest pathology where?

A

CN III

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10
Q

If someone has big pupils, and coma, it may suggest pathology where?

A

midbrain

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11
Q

The vestibulocular reflex aka oculocephalic aka occulovestibular reflex –> explain it.

A

when head turns right, the eyes will look left, and then there will be a quick right nystagmus to get back to rest.

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12
Q

What are the 2 different motor responses in light coma, and what do these responses tell us about the nature of the pathology?

  • light coma is present when reflex motor response (i.e., decorticate and decerebrate posturing) can be elicited by noxious stimulation. In deep coma there is no response.
A

1) Decorticate Posturing – lesion above red nucleus
- abnormal flexor response of arm w/ extension of the legs
- flexion of upper extremities
- extension of legs
- legs internally rotated and plantar flexion
- spastic hemiparesis due to disconnections of cortex & motor centers

2) Decerebrate Posturing – lesion below red nucleus
- abnormal extensor response of of arm & leg
- extension of trunk & neck
- clenching of jaws
- stiff extension of limbs
- internal rotation of amrs
- plantar flexion of feet.

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13
Q

What are some symptoms associated with bilateral diencephalic stage (diencephalic coma)?

A
  • Cheyne-stoke respiration (crescendo-decrescendo pattern of respirations which is punctuated by periods of apnea of variable length)
  • small pupils, reactive to light (b/c midbrain is fine)
  • vestibulocular reflex is fine (pons is fine)
  • motor responses = decorticate b/c diencepheon is above the red nucleus which is located in the midbrain
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14
Q

What are some symptoms associated with bilateral midbrain stage coma?

A
  • central neurogenic hyperventilation (deep breaths at regular pace) -midbrain lesion, sparing pons.
  • pupils midposition, unresponsive to light (characteristic of midbrain lesion)
  • oculovestibular reflex is impaired due to problems w/ CN III since it resides in midbrain
  • motor responses = decerebrate (lesion is below red nucleus)
  • so level at midbrain, pt may not wake up.
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15
Q

What are some symptoms associated with bilateral pontine stage coma?

A
  • eupneic breathing (normal, good, unlabored ventilation)
  • pupils midposition, no light reflex (problems w/ CN III -midbrain)
  • oculovestibular response is impaired so problems with CN III and CNIV
  • no motor responses (b/c pons is affected where vestibular nuclei are)
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16
Q

What are some symptoms associated with unilateral diencephalic stage?

A
  • might have normal breathing or cheynes stokes
  • small pupils, good light reflex
  • oculovestibular is fine
  • motor = asymmetrical response (contralateral side affected), + babinski reflex
17
Q

What are some symptoms associated with Late third nerve stage?

*this needs to be corrected asap.

A
  • uncus can push on CN III
  • regular sustained deep breathing
  • one pupil does not respond; consensual is intact (so part of midbrain is working)
  • impaired oculovestibular response
  • motor -decorticate on one side and decerebrate on another.