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Neuroscience II Exam III - Pharm and Clinical Medicine > CLMD Stupor and Coma, Disorders of Equilibrium > Flashcards

CLMD Stupor and Coma, Disorders of Equilibrium Flashcards

1
Q

2 general causes of coma

A

Bilateral hemispheric dysfunction

Brainstem dysfunction (ARAS)

[could be both]

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2
Q

State of altered consciousness characterized by attention deficit, orientation disturbed, and stimuli misinterpreted

A

Confusion

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3
Q

State of altered consciousness characterized by disorientation, stimuli misinterpreted, visual hallucinations

A

Delirium

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4
Q

State of altered consciousness characterized by mental blunting, increased sleep, arouses to mild stimuli (voice)

A

Obtundation

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5
Q

State of altered consciousness characterized by arousal only to noxious stimuli and not environmental, only rudimentary awareness (e.g. purposful motor responses)

A

Stupor

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6
Q

State of altered consciousness characterized by unarousable, unresponsive, unaware state

A

Coma

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7
Q

Considerations for patient who presents with stupor/coma + HTN

A

Pheochromocytoma, drugs (amphetamine, cocaine, phencyclidine), increaced ICP, PRES

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8
Q

Considerations for patient who presents with stupor/coma + hypotension

A

Addison’s, sepsis, drugs (beta blockers, Ca channel blocker, TCAs, Li, sedatives, organophosphates, opioids, methanol), progression to brain death

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9
Q

Considerations for patient who presents with stupor/coma + hyperthermia

A

Infection, heat stroke, drugs (amphetamines, TCAs, cocaine, salicylates, neuroleptics), serotonin syndrome, central (pontine hemorrhage)

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10
Q

Considerations for patient who presents with stupor/coma + hypothermia

A

Hypothyroid
Hypoglycemia
Exposure
Drugs (opioids, sedatives, barbiturates, phenothiazine, EtOH)

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11
Q

Supratentorial causes of stupor and coma that affect unilateral hemisphere (mass effect)

A 
Intracerebral hemorrhage
Large MCA infarct
Subdural hematoma
Epidural hematoma
Brain abscess
Neoplasm
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12
Q

Supratentorial causes of stupor and coma that affect bilateral hemispheres

A 
Subarachnoid hemorrhage
Multiple infarcts
Venous thrombosis
Cerebral edema
Acute hydrocephalus
Multiple metastases
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13
Q

Subtentorial causes of stupor and coma

A 
Pontine hemorrhage
Basilar a. occlusion
Central pontine myelinolysis
Cerebellar hemorrhage/infarct
Cerebellar/brainstem neoplasm
Cerebellar abscess
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14
Q

Essential and nearly essential elements of neuro exam in stupor/coma pt

A 
Essential:
Pupillary responses
Corneal reflex
EOMs
Cough/gag reflex
Motor responses
Respiratory pattern

Nearly essential:
Neck stiffness
Carotid auscultation
Funduscopic exam

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15
Q

Anisocoria — which is the abnormal pupil?

A

If its large pupil, it should fail to constrict to light

If its small pupil, it should fail to dilate in dark

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16
Q

3 P’s of pinpoint pupils

A

Pontine lesion
oPiates
Pilocarpine

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17
Q

Damage to frontal gaze centers vs. pontine gaze centers

A

Frontal gaze center lesion —> deviate eyes to opposite side

Pontine gaze center lesion —> deviate eyes to same side

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18
Q

Doll’s eyes maneuver tests which area of the brain?

A

Midpons — used to assess cranial nerves III, IV, and VI

19
Q

Cold water irrigation with intact brainstem causes….

A

Eyes to deviate to irrigated side if unilateral irrigation

Eyes to deviate downward if bilateral irrigation

[low brainstem lesion responses are not there]

20
Q

What does it mean for comatose pt to have decorticate, decerebrate or flaccid posturing?

A

Decorticate (arms flexed, legs extended) — hemispheric

Decerebrate (all extremities extended) - brainstem

Flaccid - pontomedullary or metabolic

21
Q

Hyperpnea regularly alternating with apnea

A

Cheynes-Stokes respiratory pattern - indicates bilateral hemisphere or diencephalon involvement

22
Q

Central neurogenic hyperventilation indicates damage where?

A

Midbrain

23
Q

Long inspiration followed by apnea (mid/low pons)

A

Apneustic breathing

24
Q

Ataxic, or completely irreglar breathing, indicates damage where?

A

Medullary respiratory center

25
Q

Effects of uncal transtentorial herniation

A

Compression of CN III (ipsilateral dilated pupil, poor EOM, ptosis), then contralateral brainstem (ipsilateral hemiparesis, then respiratory abnormalities, fixed pupils, and death

26
Q

Central transtentorial herniation

A

Early coma, small pupils, normal EOMs, posturing and later bilateral fixed pupils, respiratory arrest and death

27
Q

Signs/symptoms of diffuse/metabolic coma

A

Confusion and stupor commonly precede motor signs

Motor signs usually symmetrical

Pupillary reactions usually preserved

Asterixis, myoclonus, tremor, seizures common

Acid-base imbalance with hyepr or hypoventilation frequently seen

Level of consciousness may fluctuate

28
Q

Definition of brain death

A

Irreversible

Complete cessation of brain function (including respiration but not heartbeat)

Persistence

29
Q

Management of comatose pt

A

ABCs first

H and P

EKG to monitor for arrhythmias

Give glucose and thiamine

Give antidote if necessary (narcan)

Adjust body temp

Control agitation

Stop seizures if present

Labs: venous blood, arterial blood, urine, LP if neck stiffness

Diagnostic tests: noncontrast CT, LP, possibly MRI and EEG

30
Q

Importance of Romberg test

A

Tests proprioceptive ability (judges posture), not necessarily cerebellum

31
Q

Which nonvertiginous altered static/dynamic balance condition is associated with a Romberg sign?

A

Sensory disequilibrium: proprioceptive deficit, visual impairment, compensated vestibular disorders, worse in the dark

Motor and cerebellar disequilibrium do not show Romberg sign

32
Q

Typical direction of nystagmus in peripheral vs. CNS pathology

A

Peripheral: horizontal/diagonal

Central: can be vertical

33
Q

Clinical syndrome characterized by brief recurrent episodes of vertigo triggered by changes in head position with respect to gravity; thought due to debris floating in endolymph of any of the semicircular canals (posterior most commoN)

A

BPPV

34
Q

What in-office maneuver is typically used to diagnose BPPV?

A

Dix-Hallpike

In posterior canal BPPV, nystagmus is provoked with affected ear down

In anterior canal BPPV, nystagmus is provoked with affected ear up

35
Q

Treatment for BPPV

A

Vestibular suppressants (meclizine, scopolamine, valium)

Antiemetics

Anxiolytics

Physical therapy and positional exercises often helpful

36
Q

Spontaneous attack of vertigo that does not involve hearing loss or tinnitus and resolves spontaneously; characterized by vertigo, nausea, and vomiting of acute onset, typically lasting up to 2 weeks and not characteristically positional

A

Vestibular neuronitis

37
Q

Conditions characterized by recurrent episodes of spontaneous vertigo, low frequency hearing loss, tinnitus, and aural fullness possibly d/t increase in volume of labyrinthine endolymph because of poor absorption (endolymphatic hydrops)

Onset between 20-50 y/o, M:F 1:3

A

Menieres disease

38
Q

Drug-induced causes of equilibrium disorders

A 
Alcohol
Salicylates
Antiepileptics (phenytoin, carbamazepine)
Quinine compounds
Abx (aminoglycosides)
Diuretics
Chemotherapeutics
39
Q

Obligatory features of friedrich’s ataxia

A

Onset before age 20
Gait ataxia
Progression of ataxia to involve all 4 limbs
Dysarthria
Impaired position/vibratory sense in legs
Muscle weakness
Absent tendon reflexes in legs

[secondary features: extensor plantar responses, pes cavus, scoliosis, cardiomyopathy, +/- optic atrophy, nystagmus]

40
Q

Progressive pancerebellar degeneration involving nystagmus, dysarthria, and gait, limb, and trunk ataxia which begins in infancy (<4 y/o)

Characterized by progressive ataxia, oculocutaneous cutaneous findings, and immunologic deficiency

A

Ataxia-telangiectasia

41
Q

Vitamin deficiency associated with insidious onset, vague fatigue, gait and balance problems, distal sensory loss, babinski signs, romberg sign, +/- Lhermitte sign

A

Vit B12 Deficiency

[note that nitric oxide can deplete vit B12 and lead to these symptoms]

42
Q

What deficiency might present very similarly to vit b12 def?

A

Copper deficiency

43
Q

What vitamin deficiency presents as spinocerebellar similar to friederich’s and is associated with peripheral neuropathy?

A

Vit E deficiency

Neuroscience II Exam III - Pharm and Clinical Medicine (10 decks)

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