Clinical Approach to Stupor and Coma (Hon) Flashcards

1
Q

What generally causes coma?

A

Bilateral hemispheric dysfunction
Brainstem dysfunction
or
Both

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the requirements of consciousness?

A

1) Arousal

2) Awareness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Consciousness depends on arousal of cerebral cortex by?

A

The brainstem ascending reticular activating system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Coma and stupor are caused by?

A

Impaired consciousness

1) Diffuse or bilateral impairment of cerebral hemispheres
2) Failure of brainstem ARAS
3) Both the above

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are broad categories of lesions that produce coma?

A

1) Large, pressure producing Supratentorial mass lesions that involve ARAS
2) Infratentorial mass lesions that involve the brainstem
3) Diffuse or multifocal brain disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are broad categories of lesions that produce coma?

A

1) Large, pressure producing Supratentorial mass lesions
2) Infratentorial mass lesions that involve the brainstem
3) Diffuse or multifocal brain disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are some examples of supratentorial causes of stupor and coma that affect the unilateral hemisphere (mass effect)?

A

1) Intracerebral hemorrhage
2) Large MCA infarct
3) Subdural hematoma
4) Epidural hematoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are some examples of supratentorial causes of stupor and coma that affect bilateral hemisphere?

A

1) Subarachnoid hemorrhage
2) Cerebral edema
3) Acute hydrocephalus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are some examples of subtentorial causes of stupor and coma?

A

1) Pontine hemorrhage
2) Basilar artery occlusion
3) Central pontine myelinolysis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What causes the pupil to be enlarged on one side?

A

Parasympathetic dysfunction (usually CN III)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What causes pinpoint pupils?

A

1) Pontine lesions
2) Opiates
3) Pilocarpine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What extraocular movement is common to see in comatose patients?

A

Roving eye movements

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

If the roving eye movements are moving together (conjugate) this implies?

If they are dysconjugate this implies?

A

1) Brainstem intact

2) Brainstem lesion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Which direction do the eyes move with a destructive hemispheric lesion?

With an irritative hemispheric lesion?

With a destructive brainstem lesion?

A

1) Toward lesion
2) Away from lesion
3) Away from lesion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Oculocephalic maneuver (Doll’s Eyes) is used to assess which CNs?

A

III, IV, and VI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

When performing the Oculocephalic maneuver, what direction do the eyes move with passive horizontal head rotation?

what direction do the eyes move with passive vertical head rotation?

A

1) Horizontally opposite

2) Vertically opposite

17
Q

When performing a caloric (oculovestibular) reflex what to you first want to make sure of?

A

Canal is clear and TM intact

18
Q

Unilateral cold water irrigation with intact brainstem causes the eyes to deviate to which side?

Bilateral irrigation?

A

1) Toward irrigated side

2) Downward

19
Q

A patient in the decorticate position points to the issue located where? What does this look like?

If they are in the decerebrate position?

A

1) Hemispheric; arms flexed, legs extended

2) Brainstem; all extremities extended

20
Q

The initial signs of supratentorial mass lesions are usually?

The progression of signs are?

Motor signs are often?

A

1) Focal
2) Rostral to caudal
3) Asymmetric

21
Q

Herniation Syndromes are caused by?

A

Expanding supratentorial mass lesions

22
Q

The effect of herniation syndrome is to?

A

Displace brain tissue into adjacent intracranial compartments

23
Q

Uncal transtentorial herniations causes what do be compressed?

What does this cause initially?

What progressive sign is seen next?

A

1) CN III
2) Ipsilateral dilated pupil
3) Ipsilateral hemiparesis

24
Q

What are usually present with subtentorial mass lesions?

A

Cranial nerve palsies

25
Q

With diffuse/metabolic causes coma, what usually precedes motor signs?

Motor signs are usually?

A

1) Confusion and stupor

2) Symmetrical

26
Q

What are some general causes of diffuse/metabolic coma?

A

1) Hepatic/renal failure
2) Hyper/hypoglycemia
3) Hyper/hyponatremia
4) Endocrine disorders

27
Q

What occurs whenever blood flow is inadequate to meet the metabolic requirements of the brain, as in cardiac or pulmonary arrest?

A

Global Cerebral Ischemia

28
Q

Global Cerebral Ischemia usually lasts for how long?

A

≤ about 6 minutes

29
Q

What is brain death by definition?

A

1) Irreversibility
2) Complete cessation of brain function (including respiration but not heartbeat)
3) Persistence

30
Q

In order to determine cessation of all brain function, what is the gold standard to confirm this?

(She emphasized this)

A

Apnea test

31
Q

What is the apnea test?

She emphasized this

A

Respiratory responses are absent at 8 to 10 minutes

after the patient’s pC02 is allowed to rise to 60mmHg, while oxygenation is maintained with 100% O2

32
Q

If a comatose patient is febrile and a source cannot be determined and the CT is normal, what should be the next step?

(She emphasized this)

A

Lumbar puncture