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NMSP Exam 2 > Clin: Stupor & Coma - Sachen > Flashcards

Clin: Stupor & Coma - Sachen Flashcards

1
Q

total awareness of self and environment

A

consciousness

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2
Q

level of alertness, ability to interact with environment

A

arousal

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3
Q

sum of cognitive mental function; know what’s going on

A

awareness

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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

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5
Q

set of connected nuclei in the brain that is responsible for regulating wakefulness and sleep-wake transitions

A

ascending reticular activating system

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6
Q
  1. diffuse or bilateral impairment of both cerebral hemispheres
  2. failure of brainstem ARAS
  3. or BOTH
A

impaired consciousness

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7
Q

attention deficit, orientation disturbed, stimuli misinterpreted

A

confusion

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8
Q

disorientation, stimuli misinterpreted, hallucinations (visual)

A

delirium

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9
Q

mental blunting, increased sleep, arouses to mild stimuli (voice)

A

obtundation

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10
Q

arouses only to noxious stimuli and not environmental, only rudimentary awareness (purposeful motor responses)

A

stupor

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11
Q

unarousable, unresponsive, unaware

A

coma

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12
Q

no reproducible response to stimuli

  • eye may be open
  • roving eye movements
  • unaware
  • BP/pulse stable
A

persistent vegetative

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13
Q

no spontaneous motor activity

A

akinestic mutism

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14
Q

normal sensation/cognition but complete paralysis except for vertical eye movements

A

locked-in state (Monte Cristo Syndrome)

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15
Q

changing/inconsistent physical examination

- +/- altered/arousal states

A

psychogenic

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16
Q

when would you see raccoon eyes or Battle’s sign

A

during trauma

- look for CSF leak

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17
Q

when would you see neck stiffness?

A

meningitis, or subarachnoid hemorrhage

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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

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19
Q

what sign/sx should be expected with:

- pheochromocytoma, drugs (amphetamine, cocaine, phencyclidine, increased ICP, PRES)

A

hypertension

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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

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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

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22
Q

what sign/sx should be expected with:

- hypothyroid, hypoglycemia, drugs (opioids, sedatives, barbiturates, phenothiazine, EtOH)

A

hypothermia

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23
Q

what sign/sx should be expected with:

- thyroid storm, drugs (sympathomimetics, cholinergics)

A

diaphoresis

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24
Q

what sign/sx should be expected with:

- hypotheyroid, drugs (anticholinergics, TCA’s)

A

dry skin

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25
Q

what sign/sx should be expected with:

- long term antiepileptic use

A

acne

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26
Q

what sign/sx should be expected with:

- systemic lupus

A

butterfly rash

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27
Q

what sign/sx should be expected with:

- Addison’s disease

A

dark pigmentation

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28
Q

what sign/sx should be expected with:

- myxedema coma

A

cold, puffy, yellowish

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29
Q

what sign/sx should be expected with:

- acute hepatic or renal failure

A

edema

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30
Q

what sign/sx should be expected with:

- meningococcal meningitis, Thrombotic Thrombocytopenic Purpura (TTP), Disseminated Intravascular Coagulation (DIC)

A

purpura

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31
Q

what sign/sx should be expected with:

- meningitis, viral encephalitis, rckettsia

A

rash

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32
Q

what breath odor would you see with:

- ketoacidosis

A

fruity

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33
Q

what breath odor would you see with:

- hepatic failure

A

musty

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34
Q

what breath odor would you see with:

- paraldehyde (rarely used anymore to treat seizures)

A

onion

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35
Q

what breath odor would you see with:

- organophosphates (insecticides, herbicides, sarin)

A

garlic

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36
Q

what type of brain lesions case:

  • dysfunction in the upper ARAS
  • downward herniation of the brain to compress the ARAS
A

large, pressure producing supratentorial mass lesions

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37
Q

what are the examples of unilateral hemisphere bleeds that can cause stupor/coma?

A 
intracerebral hemorrhage
large MCA infarct
subdural hematoma
epidural hematoma
brain abscess
neoplasm
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38
Q

what are examples of bilateral hemisphere bleeds that can cause stupor/coma?

A 
subarachnoid hemorrhage
multiple infarcts
venous thrombosis
cerebral edema
acute hydrocephalus
multiple metastases
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39
Q

what are examples of subtentorial bleeds that can cause stupor/coma?

A 
pontine hemorrhage
basilar artery occlusion
central pontine myelinolysis
cerebellar hemorrhage/infarct
cerebellar/brainstem neoplasm
cerebellar abscess
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40
Q

what are the most important diffuse causes of stupor/coma?

A 
meningitis/encephalitis
hypoglycemia
hyperglycemia
hyponatremia
hepatic failure
malignant hypertension
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41
Q

what are the 6 essential elements of the neurological exam?

A
  1. pupillary responses
  2. corneal reflex
  3. extraoccular movements
  4. cough/gag reflex
  5. motor responses
  6. respiratory pattern
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42
Q

what does pupillary response test?

A

pons

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43
Q

what does corneal reflex test?

A

pons/midbrain

- CN 2/3

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44
Q

what do extraoccular movements test?

A

pons

- CN 3/6

45
Q

what does the cough/gag reflex test?

A

lower pons

- CN 9/10

46
Q

what do motor responses test?

A

whole brainstem

47
Q

what do respiratory patterns test?

A

cervical/medullary junction

48
Q

what are the 3 nearly essential elements of the neurological exam?

A
  1. neck stiffness
  2. carotid auscultation
  3. fundoscopic exam
49
Q

if you put cold water in someones ear drum, which way should their eyes move?

A

eyes deviate toward, nystagmus is opposite (C->O, W->S)

- testing CN 3/6/8

50
Q

what is the sympathetic path of the pupillary response?

A

hypothalamus -> lower cervical cord -> sympathetic chain -> superior cervical ganglion -> carotid artery to NC6, long ciliary nerve (dilator), mueller’s muscle

51
Q

what is the parasympathetic path of the pupillary response?

A

upper midbrain (Edinger Westfall nuc) -> CN 3 -> ciliary ganglion -> short ciliary nerve (constrictor)

52
Q

what do absent or unequal pupil responses imply?

A

a brainstem lesion

- nuclei/tracts controlling pupils are anatomically adjacent to ARAS

53
Q

what is anisocoria?

A

uneven dilation of the pupils

- indicates CN 3 dysfunction

54
Q

what is the rule of thumb for the larger pupil in anisocoria?

A

it should fail to constrict to light

55
Q

what is the rule of thumb for the smaller pupil in anisocoria?

A

it should fail to dilate in dark

56
Q

what does it mean if both pupils are enlarged bilaterally?

A

bilateral CN3 lesion, post ictal, or intoxication

57
Q

what does it mean if both pupils are constricted?

A

sympathetic dysfunction

- hypothalamus or carotid

58
Q

what do pinpoint pupils indicate?

A

the 3 P’s:
Pontine lesion, oPiates, or Pilocarpine
- (also Phenobarbital, but not really used anymore)

59
Q

what do midposition and unreactive pupils indicate?

A

sympathetic and parasympathetic issue (midbrain)

60
Q

what do atropine/scopolamine do to pupils?

A

dilated, fixed

61
Q

what do hypothermia, anoxia, ischemia do to pupils?

A

possibly dilated, fixed, unequal

62
Q

conjugate gaze depends on which cranial nerves being in tact?

A

3, 4, 6

63
Q

where do frontal gaze centers deviate to?

A

opposite eyes

64
Q

where do pontine gaze centers deviate to?

A

same side

65
Q

what do dysconjugate roving eye movements indicate?

A

brainstem lesion

66
Q

what way do the eyes move if there is a destructive hemispheric lesion?

A

toward the lesion

67
Q

what way do the eyes move if there is an irritative lesion?

A

away from the lesion

68
Q

what way do the eyes move if there is a destructive brainstem lesion?

A

away from the lesion

69
Q

what is ping-pong nystagmus, and where would you find a lesion?

A

right-left deviation every few seconds

- bihemispheric, midbrain

70
Q

what is convergent nystagmus, and where would you find the lesion?

A

slow abduction with rapid jerk back

- mesencephalon

71
Q

what is refractory nystagmus, and where would you find the lesion?

A

retraction back into orbit

- mesencephalon

72
Q

what is bobbing nystagmus, and where would you find the lesion?

A

rapid down, slow up

- pons

73
Q

what is dipping nystagmus, and where would you find the lesion?

A

slow down, rapid up

- bihemispheric

74
Q

what is the oculocephalic (Doll’s Eyes) maneuver, and what CN’s does it test?

A

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
Q

what is the caloric (oculovestibular) reflex, and what area of the brainstem does it test?

A

irrigate TM with COLD water

  • tests lower pons
  • intact brainstem -> nystagmus opposite, eyes deviate toward
76
Q

what should happen if cold water is irrigated bilaterally with intact brainstem?

A

eyes should deviate downward

77
Q

what happens if cold water is irrigated and there is a low brainstem lesion?

A

no movement

78
Q

what is decorticate posturing?

A

arms flexed, legs extended (hemispheric)

79
Q

what is decerebrate posturing?

A

all extremities extended (brainstem)

80
Q

what does flaccid posturing indicate?

A

pontomedullary or metabolic issue

81
Q

hyperpnea regularly alternating with apnea (bilateral hemispheres or diencephalon)
- seen in many disorders ranging from metabolic to structural

A

cheyne-stokes respirations

- bihemispheric or brainstem issue

82
Q

long inspiration followed by apnea for 2-3 seconds (mid/low pons)
- seen in structural lesions and anoxia, hypoglycemia, meningitis

A

apneustic breathing

83
Q

what is ataxic breathing?

A

completely irregular

- indicates problem with medullary respiratory center

84
Q

what does central neurogenic hyperventialation indicate?

A

midbrain lesion

85
Q

with a supratentorial mass lesion, progression of signs is usually in what direction?

A

rostral -> caudal

86
Q

in a supratentorial mass lesion, motor signs are usually what?

A

asymmetric

87
Q

what causes herniation syndrome?

A

expanding supratentorial mass lesions
- effect is to displace brain tissue into adjacent intracranial compartments (rostral to caudal progression of herniation)

88
Q

what is the most common herniation syndrome?

A
  • *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
Q

what is central transtentorial herniation?

A

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
Q

what is a cingulate gyrus herniation?

A

herniation under the falx

91
Q

what are typical signs of brainstem dysfunction?

A

dysequilibrium, dysarthria, dysphagia, diplopia, vertigo

92
Q

what are the 1st signs of coma d/t metabolic reasons?

A

confusion and stupor commonly precede motor signs

93
Q

motor signs are usually symmetrical

  • pupillary reactions are usually preserved
  • asterixis, myoclonus, tremor, seizures
  • acid-base imbalance with hyper or hypoventilation
  • LOC may fluctuate
A

diffuse/metabolic coma

94
Q

what are the 3 main causes of diffuse/metabolic coma?

A
  1. hepatic/renal failure
  2. hyper/hypoglycemia
  3. hypoxia
95
Q

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

A

global cerebral ischemia

96
Q

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
A

global cerebral ischemia

97
Q

focal cerebral dysfunction
- pts usually comatose for at least 12 hrs and may have lasting focal or multifocal motor, sensory, and cognitive deficits

A

prolonged ischemic episodes

98
Q

awake but functionally decorticate and unaware of surroundings
- eye opening, eye movements, sleep-wake cycles, and brainstem/spinal reflexes may remain intact

A

persistent vegetative state

99
Q

what does hte definition of brain death imply?

A
  • irreversibility
  • complete cessation of brain function (including respirations but not heartbeat)
  • persistence
100
Q

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

A

irreversibility

101
Q
  • unresponsiveness: patient must be unresponsive to all sensory input, including pain and speech
  • absent brain reflexes: including pupillary, corneal, oculocephalic, and oculovestibular reflexes
A

cessation of brain function

102
Q

what is the apnea test?

A

respiratory responses absent 8-10 minutes after the patients pCO2 is allowed to rise to 60mmHg, while oxygenation is maintained with 100% O2

103
Q

what is the criteria for persistence of brain death?

A
  • 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
Q

what are the initial steps for management of the comatose patient ?

A
  1. insure patent airway
  2. insure breathing and adequate oxygenation
  3. insure adequate circulation and control any active bleeding
105
Q

what additional tests should be run if comatose patient is febrile?

A

blood cultures (+/- CSF)

106
Q

what additional test should be run if comatose patient has a stiff neck?

A

lumbar puncture (after CT), with CSF for cell count, glucose, protein, gram stain, cultures (bacterial, viral, and fungal)

107
Q

what diagnostic testing should be run in comatose patient?

A
  • noncontrast CT
  • LP
  • MRI
    EEG
108
Q

what are the specific interventions for comatose patient?

A
  • reduce elevated intracranial pressure (elevate head, intubate)
  • treat seizures (lorazepam, phenytoin)

NMSP Exam 2 (13 decks)

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