[CLMD] Stupor and Coma [Sachen] Flashcards
Consciousness is defined by?
Total Awareness of Self and Environment
- must be alert, and able to interact with the environment
- must be aware (know whats going on)
Consciousness is arousal of the Cerebral Cortex by what?
Ascending Reticular Activating System
(ARAS)
The ARAS projects to what regions of the brain?
Hypothalamus
Thalamus
Cortex
When we talk about impaired consciousness what do we mean?
Diffuse or Bilateral Impairment of Both Cerebral Hemispheres
or
Failure of Brainstem ARAS
or
all of the above
States of Altered Consciousness
What is Confusion?
Attention Deficit, Orientation Disturbed, stimuli misinterpreted
(Alert, but not oriented)
States of Altered Consciousness
What is Delirium?
Disoriented, Stimuli misinterpreted, HALLUCINATIONS (visual)
States of Altered Consciousness
What is Stupor?
Pt only arouses to NOXIOUS stimuli (pinching etc), not environmental (only rudimentary awareness)
States of Altered Consciousness
What is Coma?
Not Aroused, Responsive, Aware
Are the states of Altered consciousness fixed states?
No! you pass through any/all of them on the way to or from coma.
When Assessing a comatose pt, what are the steps?
History
General Med Examination
Neuro Exam
Lab Eval
Dx/Tx
When taking a History, what are some examples of Sudden vs Gradual onset stupor or coma?
Sudden –> Vascular
Gradual –> Liver Failure/Drug Intoxication
What are some things to consider asking the family of a stuporess/comatose pt?
How and When Pt was found
Sudden or Gradual Onset
Prior Illness
Recent Symptoms (fever, confusion)
History of Substance Abuse
When doing a general exam on a comatose pt what are some things to consider?
Vitals
Skin
Breath Odor
Signs of Trauma
Neck Stiffness
If a patient has HTN what are some neurological considerations?
Pheochromocytoma,
Drugs (amphetamines, cocaine, phencyclidines)
Increased ICP
PRES
If a patient has hypotension what are some neurological considerations?
Addisons dz
Sepsis
Drugs (beta Blocker, Ca Ch Blocker, TCAs, Li, Sedatives etc)
(can lead to brain death)
If a patient is hyperthermic what are some neurologic considerations?
Infection
Heat Stroke
Drugs (Amphetamines, TCA’s, Cocaine, Salicyclates, Neuroleptics)
Serotonin Syndrome
Central Pontine Hemorrhage
If a patient is Hypothermic what are some neurologic considerations?
Hypothyroid
Hypoglycemic
Exposure
Drugs (opioids, sedatives, barbs, phenothiazine, Alcohol)
If a patient comes in with the following breath odors what are your considerations?
Dirty Restroom –>
Fruity –>
Musty –>
Onion –>
Garlic –>
Dirty Restroom –> Uremia
Fruity –> Ketoacidosis
Musty –> Hepatic Failure
Onion –> Paraldehyde (not used anymore to tx seizures)
Garlic –> Organophosphates (insecticies)
What are the 3 broad categories that produce coma?
Large, Pressure prodcing Supratentorial Mass Lesions
Infratentorial Mass Lesions (involving brainstem)
Diffuse of Multifocal Brain Disease
What are some causes of Supratentorial Stupor and Coma?
What are some causes of Subtentorial stupor and coma?
Pontine Hemorrhage
Basilar A occlusion
Central Pontine Myelinolysis
Cerebellar Hemorrhage/infarct
Cerebellar/Brainstem neoplasm
Cerebellar Abscess
What are some examples of Toxic Metabolic (Diffuse) Casues of stupor and coma?
Hypoxia
Meningitis/Encephalitis
Hypoglycemia
Hyperglycemia
Hyponatremic
Hepatic Failure
Malig. HTN
Drug Withdrawl
Seizures
For each of the Essential parts of the Neuro Exam what are the corresponding parts of the brainstem that you are testing?
Pupillary responses
Corneal Reflex
Extraocular Movements
Cough/Gag
Motor Responses
Respiratory Pattern
Pupillary responses –> Midbrain
Corneal Reflex –> Pons/Midbrain Jxn
Extraocular Movements –> Pons
Cough/Gag –> Lower Pons/Upper Medulla
Motor Responses –> All levels
Respiratory Pattern –> Cervical/Medullary Jxn
What are the nearly essential parts of a neuro exam?
Neck Stiffness
Carotid Auscultation
Fundoscopic Exam
What is the step wise pattern to test the Brainstem Reflex Pathway?
1st) Pupil reflex
2nd) Corneal Reflex
3rd) Cold Water Irrigation of each eye
4th) Gag Reflex
5th) Pressure on Supraorbital N
For each of the following what Nerves are you testing?
1st) Pupil reflex
2nd) Corneal Reflex
3rd) Cold Water Irrigation of each eye [COWS pneumonic]
4th) Gag Reflex
5th) Pressure on Supraorbital N
1st) Pupil reflex –> 2/3
2nd) Corneal Reflex –> 5/7
3rd) Cold Water Irrigation of each eye –> 3/4/6/8
4th) Gag Reflex –> 9/10
5th) Pressure on Supraorbital N –> 5/7
When Evaluating the Pupillary responses what is the Sympathetic Pathway?
[1st order Neuron] Hypothalamus –> Lower Cervical Cord –> Symp chain
[2nd order neuron] Symp Chain –> Superior cervical ganglion
[3rd Order Neuron] SCG –> up carotid A. to CN V, Long Ciliary N –> Muellers Muscle
When Evaluating the pupillary response what is the Parasympathetic pathway?
Upper midbrain (Edinger-Westfall N) –> CN 3 –> Ciliary Ganglion –> Short Ciliary N (Constrictor)
If you find absent or unequal responses when doing the pupillary response, what does this mean?
Brainstem Lesion
When you are evaluating Anisocoria, how do you know which is the abnormal pupil?
It its a large pupil –> it wont constrict to light
it its a small pupil –> it wont dilate in dark
What are the following locations for the common pupillary responses?
Enlarged Pupil on One Side
Enlarged Bl
Constricted
Pinpoint
Midposition/Unreactive
Enlarged Pupil on One Side –> Parasymp Dsfxn, CN 3
Enlarged Bl –> B/l CN 3, PostIctal, intoxications
Constricted –> Symp Dsfxn (hypothalamus/carotid)
Pinpoint –> Pontine Lesions, Opiates, Pilocarpine
Midposition/Unreactive –> Symp + Parasymp (midbrain)
What are the 3 P’s of Pinpoint Pupils?
Pontine Lesion
oPiates
Pilocarpine
How do each of the following affect pupillary signs?
Atropine/Scopalomine
Opiates
Pilocarpine
Hyperthermia, Anoxia, Ischemia
Atropine/Scopalomine –> Dilated, Fixed
Opiates –> Pinpoint, +/- reactive
Pilocarpine –> Pinpoint
Hyperthermia, Anoxia, Ischemia –> Possibly Dilated, Fixed, Unequal (Midposition)
What is the difference between Frontal vs Pontine Gaze Centers?
Frontal Gaze Centers deviate eyes to OPP side
Pontine deviate eyes to SAME side
What do we mean when we say the following:
Conjugate Roving EOM Movements
Dysconjugate Roving EOM Movements
Conjugate –> brainstem intact
Dysconjugate –> brainstem lesion
When we are talking about a Hemispheric Lesion what do we mean by the following?
Destructive
Irritative
Destructive –> eyes go Toward lesion
Irritative –> eyes go Away from lesion
When we are talking about a Brainstem lesion what do we mean by a destructive lesion?
Eyes move away from lesion
If a patient comes in with Nystagmus and presents with any of the following. What are locations of the lesions?
Ping-Pong (R-L deviation)
Convergence (rapid abduction with rapid jerk back)
Retractory (retraction orbit)
Bobbing (rapid down, slow up)
Dipping (rapid up, slow down)
Ping-Pong –> Bihemispheric, Midbrain
Convergence –> Mesencephalon
Retractory –> Mesencephalon
Bobbing –> Pons
Dipping –> Bihemispheric
What is the Oculocephalic Maneuver (Dolls Eyes) test testing?
Testing CN 3,4,6
location is MidPons
What is the Caloric (oculovestibular reflex) reflex test testing?
Lower Pons
Puts Cold water in 1 ear –> Eyes deviate to irrigated side if unilateral irrigation
Puts cold water in both ears –> eyes deviate downward
What is the difference between Decorticate vs Decerebrate posturing?
Decorticate –> Arms Flexed, Legs Extended (hemispheric)
Decerebrate –> all extremities extended (brainstem)
A Flaccid positioning of a comatose patient suggests what?
Pontomedullary or Metabolic causes
What is Cheynes-Stokes respiratory pattern?
Hyperpnia regularly alternating with apnea
(b/l hemispheres or diencephalon)
What is Central Neurogenic Hyperventilation respiratory pattern?
Continous hyperventilation
Midbrain
What is Apneustic Breathing?
Long inspiration followed by apnea
(mid/low pons)
What is Ataxic respiratory pattern?
Completely irregular breathing
(Medullary Respiratory Center)
What are the 4 main categories of causes of stupor or coma?
Supratentorial
Subtentorial
Diffuse/Metabolic
Psychiatric
Progression of signs for supratentorial mass lesions usually move in what direction?
Rostral to Caudal
Motor Signs are Asymmetric
What is usually caused by a Supratentorial Mass Lesion?
Herniation (the so called rostral to caudal progression of herniation)
What are the 3 types of Herniation syndromes seen in SupraTentorial Mass Lesions?
Uncal Transtentorial
Central Transtentorial
Cingulate Gyrus
Which type of herniation, goes under the edge of the tentorium compression CN 3, than contralateral brainstem, than respiratory abnormalities, posturing, fixed pupils, and death?
Uncal Transtentorial Herniation
Which herniation goes into the foramen magnum and leads to early coma, small pupils, normal EOMs, posturing and later bilateral fixed pupils, respiratory arrest, and death
Central Transtentorial Herniation
Which herniation goes under the falx?
Cingulate Gyrus Herniation
What is usually found on a Subtentorial Mass Lesion?
Preceding Brainstem Dsyfxn
Sudden Onset of Coma
Localizing Brainstem signs precede/accompany coma
Cranial Nerve Palsies present
Bizarre respiratory pattern
What is usually found when you have a Diffuse/metabolic cause?
Confusion and stupor common precede motor signs
Motor signs are symmetrical
Pupillary rxns are preserved
Asterixis, Myocolonus, Tremor, Seizures
Acid-base Imbalance
Levels of conciousness fluctuate
What are some of the top causes of diffuse/metabolic?
Hepatic Failure (renal failure less common)
Hyper/Hypoglycemia
Hypoxia
What is Global Cerebral Ischemia?
When blood flow is inadequate to meet the metabolic requirements (oxygen and glucose) of the brain (like in cardiac and pulmonary arrest)
(causes reversible encephalopathies to brain death)
What happens if someone has Breif (< 6 mins) ischemic episode?
Reversible
usually has anterograde/retrograde amnesia
recovery within 7-10 days
What is seen with Prolonged Ischemic Episodes?
Pts comatose for atleast 12 hrs, and may have lasting focal or multifocal motor, sensory, and cognitive defects
What is seen in a persistent vegetative state?
Awake, but not fxnally decorticate and unaware of surroundings
eye opening, eye movements, sleep wake cycles and brainstem and spinal reflexes usually intact
Brain death implies what?
Irreversibility
Compelte Cessation of Brain fxn
Persistence
When we talk about cessation of brain fxn what criteria does that mean?
Unresponsive to all sensory input, pain and speech
Absent Brainstem Reflexes (Pupillary, Corneal, Oculocephalic, Oculovestibular, Respiratory Responses)
What is the Apnea Test?
To see if a patient will have respiratory movements (showing braisntem fxn) when lack of oxygen is applied.
What is meant by persistence factor of brain death?
Criteria for brain death (a positive apnea test) must persist for a aggreed amount of time.
6 hours with a confirmatory flat EEG
12 hrs with a confirmatory isoelectric EEG
24 hrs for an anoxic brain injury without a confirmatory isoelectric EEG
What are the Initial Steps of managing a Comatose Pt?
Insure open airways
insure breathing and adequate oxygenation
insure adequate circulation and control any active bleeding
(Stabilize neck as well)
Quick History
GME
EKG – monitor arrythmias
Give Glucose and Thiamine
Give antidote (narcan ex)
adjust body temp
control agitation
stop seizures if present
What are some good laboratory evaluations for a comatose pt?
Venous Blood
Arterial Blood
Urine culture, drug screen
LP with CSF for cell count
What are some diagnostic tests to run on a comatose pt?
Non Contrast Head CT
LP
MRI
EEG
How can you reduce elevate ICP in a comatose pt?
Elevate head of bed
intubate and hyperventilate PCO2 of 20mm
Mannitol./Hypertonic saline for ischemic lesions
Decadron for tumor, abscess
Furosemide
How do you treat seizures in a comatose pt?
Lorazepam
Phenytoin
What is the Glasgow coma scale?
A scale of 3-15, measuring the “depth” of coma by the pts eye opening, verbal responses, and motor responses
