Clin: Stupor & Coma - Sachen Flashcards
1
Q
total awareness of self and environment
A
consciousness
2
Q
level of alertness, ability to interact with environment
A
arousal
3
Q
sum of cognitive mental function; know what’s going on
A
awareness
4
Q
depends on arousal of cerebral cortex by the brainstem ascending reticular activating system (ARAS)
- input from many sensory systems
- projects to hypothalamus, thalamus, cortex
A
consciousness
5
Q
set of connected nuclei in the brain that is responsible for regulating wakefulness and sleep-wake transitions
A
ascending reticular activating system
6
Q
- diffuse or bilateral impairment of both cerebral hemispheres
- failure of brainstem ARAS
- or BOTH
A
impaired consciousness
7
Q
attention deficit, orientation disturbed, stimuli misinterpreted
A
confusion
8
Q
disorientation, stimuli misinterpreted, hallucinations (visual)
A
delirium
9
Q
mental blunting, increased sleep, arouses to mild stimuli (voice)
A
obtundation
10
Q
arouses only to noxious stimuli and not environmental, only rudimentary awareness (purposeful motor responses)
A
stupor
11
Q
unarousable, unresponsive, unaware
A
coma
12
Q
no reproducible response to stimuli
- eye may be open
- roving eye movements
- unaware
- BP/pulse stable
A
persistent vegetative
13
Q
no spontaneous motor activity
A
akinestic mutism
14
Q
normal sensation/cognition but complete paralysis except for vertical eye movements
A
locked-in state (Monte Cristo Syndrome)
15
Q
changing/inconsistent physical examination
- +/- altered/arousal states
A
psychogenic
16
Q
when would you see raccoon eyes or Battle’s sign
A
during trauma
- look for CSF leak
17
Q
when would you see neck stiffness?
A
meningitis, or subarachnoid hemorrhage
18
Q
what lab can be run to determine CSF fluid from normal mucous?
A
order b-transferase test
- can collect clear fluid on cotton swab
19
Q
what sign/sx should be expected with:
- pheochromocytoma, drugs (amphetamine, cocaine, phencyclidine, increased ICP, PRES)
A
hypertension
20
Q
what sign/sx should be expected with:
- Addison’s, sepsis, drugs (b-blocker, Ca-channel block, TCA’s, Li, sedatives, organophosphates, opioids, methanol)
- progression to brain death
A
hypotension
21
Q
what sign/sx should be expected with:
- infection, heat stroke, drugs (amphetamines, TCA’s, cocaine, salicylates, neuroleptics), serotonin syndrome
- central pontine hemorrhage
A
hyperthermia
22
Q
what sign/sx should be expected with:
- hypothyroid, hypoglycemia, drugs (opioids, sedatives, barbiturates, phenothiazine, EtOH)
A
hypothermia
23
Q
what sign/sx should be expected with:
- thyroid storm, drugs (sympathomimetics, cholinergics)
A
diaphoresis
24
Q
what sign/sx should be expected with:
- hypotheyroid, drugs (anticholinergics, TCA’s)
A
dry skin
25
what sign/sx should be expected with:
| - long term antiepileptic use
acne
26
what sign/sx should be expected with:
| - systemic lupus
butterfly rash
27
what sign/sx should be expected with:
| - Addison's disease
dark pigmentation
28
what sign/sx should be expected with:
| - myxedema coma
cold, puffy, yellowish
29
what sign/sx should be expected with:
| - acute hepatic or renal failure
edema
30
what sign/sx should be expected with:
| - meningococcal meningitis, Thrombotic Thrombocytopenic Purpura (TTP), Disseminated Intravascular Coagulation (DIC)
purpura
31
what sign/sx should be expected with:
| - meningitis, viral encephalitis, rckettsia
rash
32
what breath odor would you see with:
| - ketoacidosis
fruity
33
what breath odor would you see with:
| - hepatic failure
musty
34
what breath odor would you see with:
| - paraldehyde (rarely used anymore to treat seizures)
onion
35
what breath odor would you see with:
| - organophosphates (insecticides, herbicides, sarin)
garlic
36
what type of brain lesions case:
- dysfunction in the upper ARAS
- downward herniation of the brain to compress the ARAS
large, pressure producing supratentorial mass lesions
37
what are the examples of unilateral hemisphere bleeds that can cause stupor/coma?
```
intracerebral hemorrhage
large MCA infarct
subdural hematoma
epidural hematoma
brain abscess
neoplasm
```
38
what are examples of bilateral hemisphere bleeds that can cause stupor/coma?
```
subarachnoid hemorrhage
multiple infarcts
venous thrombosis
cerebral edema
acute hydrocephalus
multiple metastases
```
39
what are examples of subtentorial bleeds that can cause stupor/coma?
```
pontine hemorrhage
basilar artery occlusion
central pontine myelinolysis
cerebellar hemorrhage/infarct
cerebellar/brainstem neoplasm
cerebellar abscess
```
40
what are the most important diffuse causes of stupor/coma?
```
meningitis/encephalitis
hypoglycemia
hyperglycemia
hyponatremia
hepatic failure
malignant hypertension
```
41
what are the 6 essential elements of the neurological exam?
1. pupillary responses
2. corneal reflex
3. extraoccular movements
4. cough/gag reflex
5. motor responses
6. respiratory pattern
42
what does pupillary response test?
pons
43
what does corneal reflex test?
pons/midbrain
| - CN 2/3
44
what do extraoccular movements test?
pons
| - CN 3/6
45
what does the cough/gag reflex test?
lower pons
| - CN 9/10
46
what do motor responses test?
whole brainstem
47
what do respiratory patterns test?
cervical/medullary junction
48
what are the 3 nearly essential elements of the neurological exam?
1. neck stiffness
2. carotid auscultation
3. fundoscopic exam
49
if you put cold water in someones ear drum, which way should their eyes move?
eyes deviate toward, nystagmus is opposite (C->O, W->S)
| - testing CN 3/6/8
50
what is the sympathetic path of the pupillary response?
hypothalamus -> lower cervical cord -> sympathetic chain -> superior cervical ganglion -> carotid artery to NC6, long ciliary nerve (dilator), mueller's muscle
51
what is the parasympathetic path of the pupillary response?
upper midbrain (Edinger Westfall nuc) -> CN 3 -> ciliary ganglion -> short ciliary nerve (constrictor)
52
what do absent or unequal pupil responses imply?
a brainstem lesion
| - nuclei/tracts controlling pupils are anatomically adjacent to ARAS
53
what is anisocoria?
uneven dilation of the pupils
| - indicates CN 3 dysfunction
54
what is the rule of thumb for the larger pupil in anisocoria?
it should fail to constrict to light
55
what is the rule of thumb for the smaller pupil in anisocoria?
it should fail to dilate in dark
56
what does it mean if both pupils are enlarged bilaterally?
bilateral CN3 lesion, post ictal, or intoxication
57
what does it mean if both pupils are constricted?
sympathetic dysfunction
| - hypothalamus or carotid
58
what do pinpoint pupils indicate?
the 3 P's:
Pontine lesion, oPiates, or Pilocarpine
- (also Phenobarbital, but not really used anymore)
59
what do midposition and unreactive pupils indicate?
sympathetic and parasympathetic issue (midbrain)
60
what do atropine/scopolamine do to pupils?
dilated, fixed
61
what do hypothermia, anoxia, ischemia do to pupils?
possibly dilated, fixed, unequal
62
conjugate gaze depends on which cranial nerves being in tact?
3, 4, 6
63
where do frontal gaze centers deviate to?
opposite eyes
64
where do pontine gaze centers deviate to?
same side
65
what do dysconjugate roving eye movements indicate?
brainstem lesion
66
what way do the eyes move if there is a destructive hemispheric lesion?
toward the lesion
67
what way do the eyes move if there is an irritative lesion?
away from the lesion
68
what way do the eyes move if there is a destructive brainstem lesion?
away from the lesion
69
what is ping-pong nystagmus, and where would you find a lesion?
right-left deviation every few seconds
| - bihemispheric, midbrain
70
what is convergent nystagmus, and where would you find the lesion?
slow abduction with rapid jerk back
| - mesencephalon
71
what is refractory nystagmus, and where would you find the lesion?
retraction back into orbit
| - mesencephalon
72
what is bobbing nystagmus, and where would you find the lesion?
rapid down, slow up
| - pons
73
what is dipping nystagmus, and where would you find the lesion?
slow down, rapid up
| - bihemispheric
74
what is the oculocephalic (Doll's Eyes) maneuver, and what CN's does it test?
tested by holding the eyes open and rotating the head from side to side or up and down
- reflex is present if the eyes move in the opposite direction of the head movements
- **used to assess CN 3, 4, 6**
75
what is the caloric (oculovestibular) reflex, and what area of the brainstem does it test?
irrigate TM with COLD water
- tests lower pons
- intact brainstem -> nystagmus opposite, eyes deviate toward
76
what should happen if cold water is irrigated bilaterally with intact brainstem?
eyes should deviate downward
77
what happens if cold water is irrigated and there is a low brainstem lesion?
no movement
78
what is decorticate posturing?
arms flexed, legs extended (hemispheric)
79
what is decerebrate posturing?
all extremities extended (brainstem)
80
what does flaccid posturing indicate?
pontomedullary or metabolic issue
81
hyperpnea regularly alternating with apnea (bilateral hemispheres or diencephalon)
- seen in many disorders ranging from metabolic to structural
cheyne-stokes respirations
| - bihemispheric or brainstem issue
82
long inspiration followed by apnea for 2-3 seconds (mid/low pons)
- seen in structural lesions and anoxia, hypoglycemia, meningitis
apneustic breathing
83
what is ataxic breathing?
completely irregular
| - indicates problem with medullary respiratory center
84
what does central neurogenic hyperventialation indicate?
midbrain lesion
85
with a supratentorial mass lesion, progression of signs is usually in what direction?
rostral -> caudal
86
in a supratentorial mass lesion, motor signs are usually what?
asymmetric
87
what causes herniation syndrome?
expanding supratentorial mass lesions
- effect is to displace brain tissue into adjacent intracranial compartments (rostral to caudal progression of herniation)
88
what is the most common herniation syndrome?
* *uncal transtentorial**
- herniation of uncus under edge of the tentorium, compressing CN 3, then contralateral brainstem, then respiratory abnormalities, posturing, fixed pupils and death
89
what is central transtentorial herniation?
herniation into foramen magnum that leads to early coma, small pupils, normal EOM's, posturing and later bilateral fixed pupils, respiratory arrest and death
90
what is a cingulate gyrus herniation?
herniation under the falx
91
what are typical signs of brainstem dysfunction?
dysequilibrium, dysarthria, dysphagia, diplopia, vertigo
92
what are the 1st signs of coma d/t metabolic reasons?
confusion and stupor commonly precede motor signs
93
motor signs are usually symmetrical
- pupillary reactions are usually preserved
- asterixis, myoclonus, tremor, seizures
- acid-base imbalance with hyper or hypoventilation
- LOC may fluctuate
diffuse/metabolic coma
94
what are the 3 main causes of diffuse/metabolic coma?
1. hepatic/renal failure
2. hyper/hypoglycemia
3. hypoxia
95
occurs whenever blood flow is inadequate to meet the metabolic requirements (oxygen and glucose) of the brain, as in cardiac or pulmonary arrest
- the result is a spectrum of disorders, ranging from reversible encephalopathies to brain death
global cerebral ischemia
96
brief (<6 minute) ischemic episodes
- commonly reversible encephalopathies, generally after 12 hrs or less of stupor or coma
- anterograde and/or retrograde amnesia can occur
- recovery often occurs within 7-10 days, but may be delayed by 1 month or longer
global cerebral ischemia
97
focal cerebral dysfunction
- pts usually comatose for at least 12 hrs and may have lasting focal or multifocal motor, sensory, and cognitive deficits
prolonged ischemic episodes
98
awake but functionally decorticate and unaware of surroundings
- eye opening, eye movements, sleep-wake cycles, and brainstem/spinal reflexes may remain intact
persistent vegetative state
99
what does hte definition of brain death imply?
- irreversibility
- complete cessation of brain function (including respirations but not heartbeat)
- persistence
100
cause of coma should be known, it must be adequate to explain the clinical picture, and it must be irreversible
- sedative intoxication, hypothermia (<90 F), neuromuscular blocakade, and shock must be ruled out, since these conditions can produce a clinical picture that resembles brain death but are potentially reversible
irreversibility
101
- unresponsiveness: patient must be unresponsive to all sensory input, including pain and speech
- absent brain reflexes: including pupillary, corneal, oculocephalic, and oculovestibular reflexes
cessation of brain function
102
what is the apnea test?
respiratory responses absent 8-10 minutes after the patients pCO2 is allowed to rise to 60mmHg, while oxygenation is maintained with 100% O2
103
what is the criteria for persistence of brain death?
- 6 hours with a confirmatory flat EEG
- 12 hours without confirmatory isoelectric EEG
- 24 hours for anoxic brain injury without a confirmatory isoelectric EEG
104
what are the initial steps for management of the comatose patient ?
1. insure patent airway
2. insure breathing and adequate oxygenation
3. insure adequate circulation and control any active bleeding
105
what additional tests should be run if comatose patient is febrile?
blood cultures (+/- CSF)
106
what additional test should be run if comatose patient has a stiff neck?
lumbar puncture (after CT), with CSF for cell count, glucose, protein, gram stain, cultures (bacterial, viral, and fungal)
107
what diagnostic testing should be run in comatose patient?
- noncontrast CT
- LP
- MRI
EEG
108
what are the specific interventions for comatose patient?
- reduce elevated intracranial pressure (elevate head, intubate)
- treat seizures (lorazepam, phenytoin)
