Clinical Perspectives of Reticular system, Brain Death, & Coma

Question 1

What is the Lazarus sign?

Answer 1

Movement of the foot in response to pain due to intact spinal reflex. A patient may be brain dead and still exhibit the Lazarus sign

Question 2

What diagnostic tests are considered standard when a patient presents with altered mental status?

Answer 2

Finger stick glucose, CBC, CMP, urinalysis, toxicology screen, liver enzymes, blood gas, EEG

Question 3

Brain death can be diagnosed at the bedside, except in what patient populations?

Answer 3

Children, hypothermic patients

Question 4

A patient should blink in response to the cornea being touched. This is called the corneal reflex. What CN are tested?

Answer 4

CN V (afferent) & CN VII (efferent)

Question 5

How do delirium and dementia differ?

Answer 5

Delirium has a sudden onset, abnormal vital signs, and non-pathologic etiology. Dementia has a progressive onset, normal vitals, and pathologic etiology

Question 6

What are the two dimensions of consciousness?

Answer 6

Arousal & Cognition

Question 7

What are the four steps of determining brain death?

Answer 7

1. Clinical evaluation
2. Neurological evaluation
3. Ancillary tests (if applicable)
4. Documentation

Question 8

A patient with a negative gag reflex is typically intubated. What CN are tested?

Answer 8

CN IX (afferent) & CN X (efferent)

Question 9

What is the predominant function of the ascending reticular activating system?

Answer 9

Arousal

Question 10

Arousal is a vegetative function maintained by what structure in the body?

Answer 10

Brainstem, hypothalamus, thalamus

Question 11

For how long must the apnea test be performed?

Answer 11

10 minutes

Question 12

In order for a diagnosis of coma, what structures must be involved?

Answer 12

Both cerebral hemispheres, Reticular Activating System, or both

Question 13

A patient who is not oriented, does not follow commands, and requires excessive stimuli for alertness is said to have…?

Answer 13

Altered Level of Consciousness

Question 14

What questions are important in the history of a patient presenting with altered mental status?

Answer 14

What is different? How are they different? When did this start? What do you think may have caused this?

Question 15

What are the three classifications of altered mental status?

Answer 15

Delirium, dementia, psychosis

Question 16

True/False. Brain death is the death of the patient.

Answer 16

True. The brainstem is responsible for regulating involuntary actions, such as respiration, blood pressure, etc.

Question 17

A patient presents with a mild reduction in alertness. How would you describe this patient?

Answer 17

Lethargic

Question 18

Light is shined into both eyes of a comatose patient. Neither eye responds to the light and there is no constriction of either pupil. Does this patient have a positive or negative pupillary reflex?

Answer 18

Negative reflex since there was no reaction. CN II, CN III, and the Edinger-Westphal Nucleus were tested

Question 19

True/False. Delirium is a form of dementia.

Answer 19

False. Delirium is not related to dementia. While presentation may be similar, delirium does not have a pathological cause.

Question 20

What is the ice water calorics test?

Answer 20

The head is tilted to 30 degrees and the tympanic membrane is washed with ice cold water. In a typical patient, the eyes should shift in the direction of the tympanic membrane that was washed

Question 21

A patient cannot be determined as brain dead if what class of drugs is present in their system?

Answer 21

Barbituates

Question 22

What requirements must be meant for a diagnosis of brain death?

Answer 22

1. Absent brainstem reflexes
2. Absent motor reflexes
3. Absent respiratory drive
4. Normothermic
5. Non-drugged
6. Comatose
7. Irreversible brain lesion
8. No metabolic derangements

Question 23

How will a patient in a state of obtundation present?

Answer 23

Mild reduction in alertness, with increased response time to stimuli

Question 24

What brainstem reflexes are tested to make a determination of brain death?

Answer 24

Pupillary reflex, corneal reflex, gag reflex, doll’s eye maneuver, ice water calorics, motor reflex, apnea test

Question 25

What is the appearance of a positive doll’s eye maneuver?

Answer 25

There is no eye movement. The eyes spontaneously move in the direction the head was turned

Question 26

A patient appears to be in a state of deep sleep. They are aroused with continuous and vigorous stimuli, but returns to sleep when stimuli is stopped. How would you describe this patient?

Answer 26

In a state of stupor