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Maddy - NMSP Exam II > Clin - Stupor and Coma > Flashcards

Clin - Stupor and Coma Flashcards

1
Q

requirements for consciousness

A

1) arousal (level of alertness, ability to interact w/ environment)
2) awareness (know what’s going on)

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2
Q

which state of altered consciousness is represented by mental blinding, increased sleep, and arousal to mild stimuli (voice)

A

obtundation

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3
Q

what is battle’s sign

A

a bruise behind the ear that indicates a fracture at the bottom of the skull, typically temporal bone fx

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4
Q

what does a general examination of a stupor/coma patient entail

A

1) vital signs (respiratory rate and pattern)
2) skin
3) breath odor
4) signs of trauma (raccoon eyes, battles sign, CSF leak)
5) CSF stiffness

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5
Q

if a stupor/coma patients presents with HTN, what are some considerations

A
  • pheochromocytoma
  • drugs (amphetamine, cocaine, PCP)
  • increased ICP
  • PRES (posterior reversible encephalopathy syndrome)
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6
Q

if a stupor/coma patients presents with hypotension, what are some considerations

A
  • addison’s
  • sepsis
  • drugs (beta blocker, Ca2+ blocker, TCAs, lithium, sedatives, opioids)
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7
Q

if a stupor/coma patients presents with hyperthermia, what are some considerations

A
  • infection
  • heat stroke
  • drugs (amphetamines, TCAs, cocaine, salicylates, neuroleptics)
  • serotonin syndrome
  • central hemorrhage
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8
Q

if a stupor/coma patients presents with hypothermia, what are some considerations

A
  • hypothyroid
  • hypoglycemia
  • drugs (opioids, sedatives, barbiturates, alcohol)
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9
Q

During a general medical exam of the skin of a patient with impaired consciousness what should be considered with cold, puffy, yellowish appearance?

A

myxedema coma

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10
Q

During a general medical exam of the skin of a patient with impaired consciousness what should be considered with purpura?

A
  • meningococcal meningitis
  • TTP (Thrombotic thrombocytopenic purpura)
  • DIC
  • vasculitis
  • aspirin OD
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11
Q

During a general medical exam of the skin of a patient with impaired consciousness what should be considered with rash?

A

meningitis, viral encephalitis, rickettsia

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12
Q

what should you consider when a stupor/coma patient comes in with breath odor that smells like:

  • dirty restroom
  • fruity
  • musty
  • onion
  • garlic
A
  • dirty restroom: uremia
  • fruity: ketoacidosis
  • musty: hepatic failure
  • onion: paraldehyde (rare tx for seizures)
  • garlic: organophosphates (insecticides, herbicides, sarin)
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13
Q

list the bilateral supratentorial causes of coma

A
  • subarachnoid hemorrhage
  • multiple infarcts
  • venous thrombosis
  • cerebral edema
  • acute hydrocephalus
  • multiple mets
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14
Q

list the SUBtentorial causes of coma

A
  1. pontine hemorrhage
  2. basilar artery occlusion
  3. central pontine myelinolysis
  4. cerebellar hemorrhage/infarct
  5. cerebellar/brainstem neoplasm
  6. cerebellar abscess
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15
Q

describe the caloric stimulation test and what nerves it tests

A

COWS

1) pour cold water in left ear –> eyes should slowly move to right and quick movement to the left (left nystagmus)
2) pour cold water in right ear –> eyes should slowly move to left and quick movement to the right (right nystagmus)

coma pt: eyes will deviate away and then stay there

nerves 8 (stimulation from the water to the brainstem), 6 (abducting the eye), 3

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16
Q

what nerves are tested in the corneal test

A

5 and 7

17
Q

what is the rule of thumb for anisocaria?

A

if it’s the large pupil –> should fail to constrict to light

if it’s the small pupil –> should fail to dilate in the dark

18
Q

if pupils are pinpoint, what could this indicate

A
  • pontine lesion
  • opiates
  • pilocarpine
19
Q

if pupils are mid position and unreaction, what could this indicate

A

sympathetic + parasympathetic dysfunction (midbrain)

20
Q

how does atropine/scopalomine affect the pupils

A

dilated, fixed

21
Q

how does glutethimide affect the pupils

A

dilated, fixed, unequal

22
Q

how does hypothermia, anoxia, and ischemia affect the pupils

A

possibly dilated, fixed, unequal

23
Q

in hemispheric lesions, where does the eyes deviate towards with destructive and irritative lesions

A

destructive: toward lesion
irritative: away from lesion

24
Q

in brainstem lesions, were does the eye deviate towards with destructive lesions

A

away from the lesion

25
Q

dripping nystagmus (slow down, rapid up) indicates a lesion where?

A

bihemispheric

26
Q

what is the oculocephalic maneuver?

A

doll’s eye
- passive horizontal head rotation –> eyes move horizontally opposite

  • passive vertical head rotation –> eyes move vertically opposite
27
Q

in the caloric test, what happens with cold and hot bilateral irrigation

A

cold: the eyes deviate downward
hot: eyes deviate upward

28
Q

how does stupor and coma affect the oculocephalic maneuver

A

moving head side to side: eyes move with head turn

moving head up and down: eyes move with head movement

29
Q

what is apneustic breathing and in what conditions is it seen

A

long inspirational followed by apnea (mid/low pons)

seen in structural lesions and anoxia, hypoglycemia, meningitis

30
Q

what part of the brain is affected if the patient has central neurogenic hyperventilation

A

midbrain

31
Q

what part of the brain is affected if the patient has ataxic respirations

A

medullary respiratory centers

32
Q

What is uncal transtentorial herniation and the signs/symptoms?

A
  • herniation of uncus under edge of tentorium compressing CN III
  • leads to ipsilateral dilated pupil, poor EOM, ptosis
  • then ipsilateral hemiparesis
  • then respiratory abnormalities, posturing, fixed pupils and death
33
Q

what happens in a cingulate gyrus herniation

A

it herniates under the falx

34
Q

what symptoms can a pt have with a brief (<6 mins) ischemic episode

A

anterograde and/or retrograde amnesia

35
Q

how long is a prolonged ischemic episode

A

usually at least 12 hours

36
Q

list the venous and arterial blood lab tests you should get for a comatose patient

A

venous: glucose, electrolytes, BUN/creatinine, osmolality, drug screen, liver functions, ammonia, coag studies, thyroid, cultures
arterial: pH, pO2, pCO2, HCO3, HbCO

Maddy - NMSP Exam II (12 decks)

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