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Coma Flashcards

1
Q

What is consciousness?

A

Awareness of self and environment

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2
Q

What are the 2 types of alterations in consciousness?

A
  • Arousal

- Cognitive and affective mental functioning

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3
Q

What is lethargy?

A

Motor slowness

Tired/sleepy, but easily aroused

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4
Q

What is stupor?

A

Unresponsiveness from which the patient can be aroused only be vigorous, often noxious stimuli

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5
Q

What are the two mechanisms of coma?

A

Hit both hemispheres or brainstem

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6
Q

What are the two major structural locations for a coma?

A
  • Supratentorial

- Subtentorial

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7
Q

Where does arousability begin in the brain?

A

Pontine reticular activating system (reticular formation)

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8
Q

Where do the fibers from the RF go?

A

Decussate, and ascend into the thalamus, where they then project diffusely in the cortices

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9
Q

Where does the reticular activating system reside?

A

Posterior pons

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10
Q

Tumors in what location (generally) coma?

A

Pons (hitting the pontine reticular activating system)

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11
Q

True or false: stroke patients typically do not cause a LOC

A

True

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12
Q

Why are carotid artery doppler not useful for patient who lose consciousness?

A

Need to affect the pons to cause LOC, and carotids go to the cerebrum.

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13
Q

What does the anterior pons contain?

A

Motor neurons from the motor cortices

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14
Q

Locked-in syndrome is caused by a lesion where?

A

Anterior pons

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15
Q

What, generally, causes diffuse cortical involvement?

A

Toxins or diffuse problems

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16
Q

What are battle signs?

A

Postauricular ecchymosis 2/2 basilar skull fracture

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17
Q

What are Racoon eyes?

A

Periorbital ecchymoses 2/2 basilar skull fracture

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18
Q

Why is temp important with CNS s/sx?

A

Toxic

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19
Q

Which is more likely to cause a LOC: toxic or metabolic/infx problem or localized lesion

A

Toxic/metabolic/infx

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20
Q

What two parts of the neuro exam cannot be performed on a comatose pt?

A

Coordination and gait (obviously)

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21
Q

True or false: cerebral hemispheres are always unavailable with the neuro exam in comatose patients

A

True

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22
Q

What is the neuro exam focused on with a comatose patient?

A

Assess brainstem

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23
Q

What is the max score on a Glasgow coma scale? What is the lowest?

A

15

3

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24
Q

What are the three categories of the glasgow coma scale?

A
  • Eye opening
  • Verbal response
  • Motor response
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25
What parts of the brain control breathing?
Brainstem and forebrain
26
What are Cheyne-Stokes breathing?
Slow oscillation between hyper and hypoventilation
27
What is the one breathing pattern that does not result from a brainstem problem? What causes it?
Cheyne-stokes breathing Hemispheric problems
28
What is a central neurogenic respiration?
rapid, continuous hyperventilation are more than 25
29
What, generally, causes Cheyne-stokes breathing pattern?
Metabolic, infectious
30
What is apneustic breathing?
Prolonged inspiratory gasp with pause at full respiration
31
What happens to breathing patterns with lesions that are progressively inferior in the brainstem?
Become more chaotic
32
What is cluster breathing?
Periodic-respiration of variable amplitude and frequency with variable pauses between clusters
33
What is ataxic breathing?
Breathing that is completely irregular in rate and rhythm
34
What is the main question being asked with comatose patients?
"Does the brainstem work?"
35
What are the four things that are assessed with brainstem exam?
- Resp - Pupils - EOMS - Motor
36
What are thalamic pupils?
Small, but reactive
37
What are midbrain pupils?
Midposition and fixed
38
What are pontine pupils?
Pinpoint but reactive
39
What are uncal pupils?
Dilated, asymmetric and fixed (bad news)
40
What can uncal ("blown") pupils indicate?
Brain is herniating (impending death)
41
What are in the outer parts of CN III?
PNS fibers--thus motor is lost before pupillary response
42
What are usually the last thing to reveal an abnormality with a coma: respirations, Pupils, EOMs, or motor problems? What can alter this pattern?
Pupils Toxic or other diffuse effects can cause pupil dysfunction
43
Normal eye motility implies integrity in what structure?
Brainstem vestibular nuclei at the postomedulary junction
44
Normal conjugate gaze in an alert patient may be disconjugate when?
Sleep or slight alteration in consciousness d/t unmasking of strabismus
45
Conjugate ocular motility comes from where?
Frontal eye field
46
Eyes that deviate downward spontaneously = lesion where?
Brainstem
47
Dysconjugate motility of the eyes = ?
Damage to the frontal eye fields
48
Upward deviating eyes in a comatose patient = ?
Non-localizing
49
Skewed eyes in a comatose patient = ?
Brainstem or cerebellar problem
50
What is the oculocephalic reflex, and what does it indicate in a comatose patient if intact?
Doll's eye reflex Indicates that CN VIII is intact, and thus the brainstem is at least somewhat intact
51
What is the vestibulo-oculogyric reflex?
Caloric testing--cold water injected into the ear, to cause eyes to deviate toward the cold water, and away from warm water
52
What causes the Doll's eye reflex?
When Supranuclear influences on oculomotor nerves are removed, eye maintain fixation on a point in the distance when the head it turned, providing brainstem integrity
53
What is the COWS mnemonic, and when does it apply? Why?
Cold opposite Warm Same Applies only to awake pts, because the fast component of nystagmus is controlled by the hemispheres
54
How is nystagmus named?
Fast beat
55
What controls the fast beat of nystagmus?
The hemispheres
56
There is not fast component of nystagmus when?
In the comatose patient
57
Does the COWS mnemonic apply to the comatose patient?
NO-It is OPPOSITE
58
What is decorticate posturing? What does this indicate?
Bilateral flexion at the elbows and wrists with extension of the lower extremities Lesion is above the brainstem
59
What is decerebrate posturing? What does this indicate?
Bilateral extension of the elbows with extension of the lower extremities Usually bilateral or midbrain pontine
60
What is myoclonic jerking?
Non-rhythmic movement d/t metabolic causes
61
What is rhythmic myoclonus?
Brainstem issues
62
True or false: the plantar reflex may be extensor in coma for any reason
True
63
True or false:Most patients with absent cortical or brainstem function will have some form of spinal reflex
True
64
Which generally has a rapid, and which a slow onset: structural / metabolic causes of a coma?
``` Structural = rapid Metabolic = slow ```
65
What are the respirations like with metabolic problems?
Deep, frequent
66
What are the three major non-structural causes of coma?
Toxins Metabolic Infectious
67
What are the PE signs of head trauma?
- Racoon eyes - Battle signs - Hemotympanum - Rhinorrhea or otorrhea (with CSF)
68
Where is the major breathing center in the brain?
Medulla and Pons
69
What are the pupil characteristics of opioid use?
Pinpoint
70
What is the role of the vestibulo-oculogyric reflex testing?
Confirm or refute a negative Doll's eye maneuver
71
In the comatose patient, putting cold water in the right ear will cause the eyes to deviate what direction?
There is no fast nystagmus phase in the comatose patient, but the slow phase remains intact. Thus the COWS mnemonic is reversed, and the eye deviates TOWARD
72
Asymmetry with eye movements indicates a metabolic or structural problem?
Structural
73
What is the reversal agent for opioids?
Naloxone
74
What is the reversal agent for Benzos?
Flumazenil

Neurology (23 decks)

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