Clin - Stupor and Coma Flashcards
requirements for consciousness
1) arousal (level of alertness, ability to interact w/ environment)
2) awareness (know what’s going on)
which state of altered consciousness is represented by mental blinding, increased sleep, and arousal to mild stimuli (voice)
obtundation
what is battle’s sign
a bruise behind the ear that indicates a fracture at the bottom of the skull, typically temporal bone fx
what does a general examination of a stupor/coma patient entail
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
if a stupor/coma patients presents with HTN, what are some considerations
- pheochromocytoma
- drugs (amphetamine, cocaine, PCP)
- increased ICP
- PRES (posterior reversible encephalopathy syndrome)
if a stupor/coma patients presents with hypotension, what are some considerations
- addison’s
- sepsis
- drugs (beta blocker, Ca2+ blocker, TCAs, lithium, sedatives, opioids)
if a stupor/coma patients presents with hyperthermia, what are some considerations
- infection
- heat stroke
- drugs (amphetamines, TCAs, cocaine, salicylates, neuroleptics)
- serotonin syndrome
- central hemorrhage
if a stupor/coma patients presents with hypothermia, what are some considerations
- hypothyroid
- hypoglycemia
- drugs (opioids, sedatives, barbiturates, alcohol)
During a general medical exam of the skin of a patient with impaired consciousness what should be considered with cold, puffy, yellowish appearance?
myxedema coma
During a general medical exam of the skin of a patient with impaired consciousness what should be considered with purpura?
- meningococcal meningitis
- TTP (Thrombotic thrombocytopenic purpura)
- DIC
- vasculitis
- aspirin OD
During a general medical exam of the skin of a patient with impaired consciousness what should be considered with rash?
meningitis, viral encephalitis, rickettsia
what should you consider when a stupor/coma patient comes in with breath odor that smells like:
- dirty restroom
- fruity
- musty
- onion
- garlic
- dirty restroom: uremia
- fruity: ketoacidosis
- musty: hepatic failure
- onion: paraldehyde (rare tx for seizures)
- garlic: organophosphates (insecticides, herbicides, sarin)
list the bilateral supratentorial causes of coma
- subarachnoid hemorrhage
- multiple infarcts
- venous thrombosis
- cerebral edema
- acute hydrocephalus
- multiple mets
list the SUBtentorial causes of coma
- pontine hemorrhage
- basilar artery occlusion
- central pontine myelinolysis
- cerebellar hemorrhage/infarct
- cerebellar/brainstem neoplasm
- cerebellar abscess
describe the caloric stimulation test and what nerves it tests
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
what nerves are tested in the corneal test
5 and 7
what is the rule of thumb for anisocaria?
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
if pupils are pinpoint, what could this indicate
- pontine lesion
- opiates
- pilocarpine
if pupils are mid position and unreaction, what could this indicate
sympathetic + parasympathetic dysfunction (midbrain)
how does atropine/scopalomine affect the pupils
dilated, fixed
how does glutethimide affect the pupils
dilated, fixed, unequal
how does hypothermia, anoxia, and ischemia affect the pupils
possibly dilated, fixed, unequal
in hemispheric lesions, where does the eyes deviate towards with destructive and irritative lesions
destructive: toward lesion
irritative: away from lesion
in brainstem lesions, were does the eye deviate towards with destructive lesions
away from the lesion
dripping nystagmus (slow down, rapid up) indicates a lesion where?
bihemispheric
what is the oculocephalic maneuver?
doll’s eye
- passive horizontal head rotation –> eyes move horizontally opposite
- passive vertical head rotation –> eyes move vertically opposite
in the caloric test, what happens with cold and hot bilateral irrigation
cold: the eyes deviate downward
hot: eyes deviate upward
how does stupor and coma affect the oculocephalic maneuver
moving head side to side: eyes move with head turn
moving head up and down: eyes move with head movement
what is apneustic breathing and in what conditions is it seen
long inspirational followed by apnea (mid/low pons)
seen in structural lesions and anoxia, hypoglycemia, meningitis
what part of the brain is affected if the patient has central neurogenic hyperventilation
midbrain
what part of the brain is affected if the patient has ataxic respirations
medullary respiratory centers
What is uncal transtentorial herniation and the signs/symptoms?
- 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
what happens in a cingulate gyrus herniation
it herniates under the falx
what symptoms can a pt have with a brief (<6 mins) ischemic episode
anterograde and/or retrograde amnesia
how long is a prolonged ischemic episode
usually at least 12 hours
list the venous and arterial blood lab tests you should get for a comatose patient
venous: glucose, electrolytes, BUN/creatinine, osmolality, drug screen, liver functions, ammonia, coag studies, thyroid, cultures
arterial: pH, pO2, pCO2, HCO3, HbCO
