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MCM mine > [CLMD] Stupor and Coma [Sachen] > Flashcards

[CLMD] Stupor and Coma [Sachen] Flashcards

1
Q

Consciousness is defined by?

A

Total Awareness of Self and Environment

  • must be alert, and able to interact with the environment
  • must be aware (know whats going on)
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2
Q

Consciousness is arousal of the Cerebral Cortex by what?

A

Ascending Reticular Activating System

(ARAS)

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3
Q

The ARAS projects to what regions of the brain?

A

Hypothalamus

Thalamus

Cortex

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4
Q

When we talk about impaired consciousness what do we mean?

A

Diffuse or Bilateral Impairment of Both Cerebral Hemispheres

or

Failure of Brainstem ARAS

or

all of the above

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5
Q

States of Altered Consciousness

What is Confusion?

A

Attention Deficit, Orientation Disturbed, stimuli misinterpreted

(Alert, but not oriented)

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6
Q

States of Altered Consciousness

What is Delirium?

A

Disoriented, Stimuli misinterpreted, HALLUCINATIONS (visual)

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7
Q

States of Altered Consciousness

What is Stupor?

A

Pt only arouses to NOXIOUS stimuli (pinching etc), not environmental (only rudimentary awareness)

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8
Q

States of Altered Consciousness

What is Coma?

A

Not Aroused, Responsive, Aware

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9
Q

Are the states of Altered consciousness fixed states?

A

No! you pass through any/all of them on the way to or from coma.

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10
Q

When Assessing a comatose pt, what are the steps?

A

History

General Med Examination

Neuro Exam

Lab Eval

Dx/Tx

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11
Q

When taking a History, what are some examples of Sudden vs Gradual onset stupor or coma?

A

Sudden –> Vascular

Gradual –> Liver Failure/Drug Intoxication

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12
Q

What are some things to consider asking the family of a stuporess/comatose pt?

A

How and When Pt was found

Sudden or Gradual Onset

Prior Illness

Recent Symptoms (fever, confusion)

History of Substance Abuse

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13
Q

When doing a general exam on a comatose pt what are some things to consider?

A

Vitals

Skin

Breath Odor

Signs of Trauma

Neck Stiffness

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14
Q

If a patient has HTN what are some neurological considerations?

A

Pheochromocytoma,

Drugs (amphetamines, cocaine, phencyclidines)

Increased ICP

PRES

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15
Q

If a patient has hypotension what are some neurological considerations?

A

Addisons dz

Sepsis

Drugs (beta Blocker, Ca Ch Blocker, TCAs, Li, Sedatives etc)

(can lead to brain death)

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16
Q

If a patient is hyperthermic what are some neurologic considerations?

A

Infection

Heat Stroke

Drugs (Amphetamines, TCA’s, Cocaine, Salicyclates, Neuroleptics)

Serotonin Syndrome

Central Pontine Hemorrhage

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17
Q

If a patient is Hypothermic what are some neurologic considerations?

A

Hypothyroid

Hypoglycemic

Exposure

Drugs (opioids, sedatives, barbs, phenothiazine, Alcohol)

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18
Q

If a patient comes in with the following breath odors what are your considerations?

Dirty Restroom –>

Fruity –>

Musty –>

Onion –>

Garlic –>

A

Dirty Restroom –> Uremia

Fruity –> Ketoacidosis

Musty –> Hepatic Failure

Onion –> Paraldehyde (not used anymore to tx seizures)

Garlic –> Organophosphates (insecticies)

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19
Q

What are the 3 broad categories that produce coma?

A

Large, Pressure prodcing Supratentorial Mass Lesions

Infratentorial Mass Lesions (involving brainstem)

Diffuse of Multifocal Brain Disease

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20
Q

What are some causes of Supratentorial Stupor and Coma?

A
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21
Q

What are some causes of Subtentorial stupor and coma?

A

Pontine Hemorrhage

Basilar A occlusion

Central Pontine Myelinolysis

Cerebellar Hemorrhage/infarct

Cerebellar/Brainstem neoplasm

Cerebellar Abscess

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22
Q

What are some examples of Toxic Metabolic (Diffuse) Casues of stupor and coma?

A

Hypoxia

Meningitis/Encephalitis

Hypoglycemia

Hyperglycemia

Hyponatremic

Hepatic Failure

Malig. HTN

Drug Withdrawl

Seizures

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23
Q

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

A

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

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24
Q

What are the nearly essential parts of a neuro exam?

A

Neck Stiffness

Carotid Auscultation

Fundoscopic Exam

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25
Q

What is the step wise pattern to test the Brainstem Reflex Pathway?

A

1st) Pupil reflex
2nd) Corneal Reflex
3rd) Cold Water Irrigation of each eye
4th) Gag Reflex
5th) Pressure on Supraorbital N

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26
Q

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

A

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

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27
Q

When Evaluating the Pupillary responses what is the Sympathetic Pathway?

A

[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

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28
Q

When Evaluating the pupillary response what is the Parasympathetic pathway?

A

Upper midbrain (Edinger-Westfall N) –> CN 3 –> Ciliary Ganglion –> Short Ciliary N (Constrictor)

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29
Q

If you find absent or unequal responses when doing the pupillary response, what does this mean?

A

Brainstem Lesion

30
Q

When you are evaluating Anisocoria, how do you know which is the abnormal pupil?

A

It its a large pupil –> it wont constrict to light

it its a small pupil –> it wont dilate in dark

31
Q

What are the following locations for the common pupillary responses?

Enlarged Pupil on One Side

Enlarged Bl

Constricted

Pinpoint

Midposition/Unreactive

A

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)

32
Q

What are the 3 P’s of Pinpoint Pupils?

A

Pontine Lesion

oPiates

Pilocarpine

33
Q

How do each of the following affect pupillary signs?

Atropine/Scopalomine

Opiates

Pilocarpine

Hyperthermia, Anoxia, Ischemia

A

Atropine/Scopalomine –> Dilated, Fixed

Opiates –> Pinpoint, +/- reactive

Pilocarpine –> Pinpoint

Hyperthermia, Anoxia, Ischemia –> Possibly Dilated, Fixed, Unequal (Midposition)

34
Q

What is the difference between Frontal vs Pontine Gaze Centers?

A

Frontal Gaze Centers deviate eyes to OPP side

Pontine deviate eyes to SAME side

35
Q

What do we mean when we say the following:

Conjugate Roving EOM Movements

Dysconjugate Roving EOM Movements

A

Conjugate –> brainstem intact

Dysconjugate –> brainstem lesion

36
Q

When we are talking about a Hemispheric Lesion what do we mean by the following?

Destructive

Irritative

A

Destructive –> eyes go Toward lesion

Irritative –> eyes go Away from lesion

37
Q

When we are talking about a Brainstem lesion what do we mean by a destructive lesion?

A

Eyes move away from lesion

38
Q

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)

A

Ping-Pong –> Bihemispheric, Midbrain

Convergence –> Mesencephalon

Retractory –> Mesencephalon

Bobbing –> Pons

Dipping –> Bihemispheric

39
Q

What is the Oculocephalic Maneuver (Dolls Eyes) test testing?

A

Testing CN 3,4,6

location is MidPons

40
Q

What is the Caloric (oculovestibular reflex) reflex test testing?

A

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

41
Q

What is the difference between Decorticate vs Decerebrate posturing?

A

Decorticate –> Arms Flexed, Legs Extended (hemispheric)

Decerebrate –> all extremities extended (brainstem)

42
Q

A Flaccid positioning of a comatose patient suggests what?

A

Pontomedullary or Metabolic causes

43
Q

What is Cheynes-Stokes respiratory pattern?

A

Hyperpnia regularly alternating with apnea

(b/l hemispheres or diencephalon)

44
Q

What is Central Neurogenic Hyperventilation respiratory pattern?

A

Continous hyperventilation

Midbrain

45
Q

What is Apneustic Breathing?

A

Long inspiration followed by apnea

(mid/low pons)

46
Q

What is Ataxic respiratory pattern?

A

Completely irregular breathing

(Medullary Respiratory Center)

47
Q

What are the 4 main categories of causes of stupor or coma?

A

Supratentorial

Subtentorial

Diffuse/Metabolic

Psychiatric

48
Q

Progression of signs for supratentorial mass lesions usually move in what direction?

A

Rostral to Caudal

Motor Signs are Asymmetric

49
Q

What is usually caused by a Supratentorial Mass Lesion?

A

Herniation (the so called rostral to caudal progression of herniation)

50
Q

What are the 3 types of Herniation syndromes seen in SupraTentorial Mass Lesions?

A

Uncal Transtentorial

Central Transtentorial

Cingulate Gyrus

51
Q

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?

A

Uncal Transtentorial Herniation

52
Q

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

A

Central Transtentorial Herniation

53
Q

Which herniation goes under the falx?

A

Cingulate Gyrus Herniation

54
Q

What is usually found on a Subtentorial Mass Lesion?

A

Preceding Brainstem Dsyfxn

Sudden Onset of Coma

Localizing Brainstem signs precede/accompany coma

Cranial Nerve Palsies present

Bizarre respiratory pattern

55
Q

What is usually found when you have a Diffuse/metabolic cause?

A

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

56
Q

What are some of the top causes of diffuse/metabolic?

A

Hepatic Failure (renal failure less common)

Hyper/Hypoglycemia

Hypoxia

57
Q

What is Global Cerebral Ischemia?

A

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)

58
Q

What happens if someone has Breif (< 6 mins) ischemic episode?

A

Reversible

usually has anterograde/retrograde amnesia

recovery within 7-10 days

59
Q

What is seen with Prolonged Ischemic Episodes?

A

Pts comatose for atleast 12 hrs, and may have lasting focal or multifocal motor, sensory, and cognitive defects

60
Q

What is seen in a persistent vegetative state?

A

Awake, but not fxnally decorticate and unaware of surroundings

eye opening, eye movements, sleep wake cycles and brainstem and spinal reflexes usually intact

61
Q

Brain death implies what?

A

Irreversibility

Compelte Cessation of Brain fxn

Persistence

62
Q

When we talk about cessation of brain fxn what criteria does that mean?

A

Unresponsive to all sensory input, pain and speech

Absent Brainstem Reflexes (Pupillary, Corneal, Oculocephalic, Oculovestibular, Respiratory Responses)

63
Q

What is the Apnea Test?

A

To see if a patient will have respiratory movements (showing braisntem fxn) when lack of oxygen is applied.

64
Q

What is meant by persistence factor of brain death?

A

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

65
Q

What are the Initial Steps of managing a Comatose Pt?

A

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

66
Q

What are some good laboratory evaluations for a comatose pt?

A

Venous Blood

Arterial Blood

Urine culture, drug screen

LP with CSF for cell count

67
Q

What are some diagnostic tests to run on a comatose pt?

A

Non Contrast Head CT

LP

MRI

EEG

68
Q

How can you reduce elevate ICP in a comatose pt?

A

Elevate head of bed

intubate and hyperventilate PCO2 of 20mm

Mannitol./Hypertonic saline for ischemic lesions

Decadron for tumor, abscess

Furosemide

69
Q

How do you treat seizures in a comatose pt?

A

Lorazepam

Phenytoin

70
Q

What is the Glasgow coma scale?

A

A scale of 3-15, measuring the “depth” of coma by the pts eye opening, verbal responses, and motor responses

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