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Neurology > Coma > Flashcards

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
Q

What parts of the brain control breathing?

A

Brainstem and forebrain

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26
Q

What are Cheyne-Stokes breathing?

A

Slow oscillation between hyper and hypoventilation

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27
Q

What is the one breathing pattern that does not result from a brainstem problem? What causes it?

A

Cheyne-stokes breathing

Hemispheric problems

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28
Q

What is a central neurogenic respiration?

A

rapid, continuous hyperventilation are more than 25

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29
Q

What, generally, causes Cheyne-stokes breathing pattern?

A

Metabolic, infectious

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30
Q

What is apneustic breathing?

A

Prolonged inspiratory gasp with pause at full respiration

31
Q

What happens to breathing patterns with lesions that are progressively inferior in the brainstem?

A

Become more chaotic

32
Q

What is cluster breathing?

A

Periodic-respiration of variable amplitude and frequency with variable pauses between clusters

33
Q

What is ataxic breathing?

A

Breathing that is completely irregular in rate and rhythm

34
Q

What is the main question being asked with comatose patients?

A

“Does the brainstem work?”

35
Q

What are the four things that are assessed with brainstem exam?

A
  • Resp
  • Pupils
  • EOMS
  • Motor
36
Q

What are thalamic pupils?

A

Small, but reactive

37
Q

What are midbrain pupils?

A

Midposition and fixed

38
Q

What are pontine pupils?

A

Pinpoint but reactive

39
Q

What are uncal pupils?

A

Dilated, asymmetric and fixed (bad news)

40
Q

What can uncal (“blown”) pupils indicate?

A

Brain is herniating (impending death)

41
Q

What are in the outer parts of CN III?

A

PNS fibers–thus motor is lost before pupillary response

42
Q

What are usually the last thing to reveal an abnormality with a coma: respirations, Pupils, EOMs, or motor problems? What can alter this pattern?

A

Pupils

Toxic or other diffuse effects can cause pupil dysfunction

43
Q

Normal eye motility implies integrity in what structure?

A

Brainstem vestibular nuclei at the postomedulary junction

44
Q

Normal conjugate gaze in an alert patient may be disconjugate when?

A

Sleep or slight alteration in consciousness d/t unmasking of strabismus

45
Q

Conjugate ocular motility comes from where?

A

Frontal eye field

46
Q

Eyes that deviate downward spontaneously = lesion where?

A

Brainstem

47
Q

Dysconjugate motility of the eyes = ?

A

Damage to the frontal eye fields

48
Q

Upward deviating eyes in a comatose patient = ?

A

Non-localizing

49
Q

Skewed eyes in a comatose patient = ?

A

Brainstem or cerebellar problem

50
Q

What is the oculocephalic reflex, and what does it indicate in a comatose patient if intact?

A

Doll’s eye reflex

Indicates that CN VIII is intact, and thus the brainstem is at least somewhat intact

51
Q

What is the vestibulo-oculogyric reflex?

A

Caloric testing–cold water injected into the ear, to cause eyes to deviate toward the cold water, and away from warm water

52
Q

What causes the Doll’s eye reflex?

A

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
Q

What is the COWS mnemonic, and when does it apply? Why?

A

Cold opposite
Warm Same

Applies only to awake pts, because the fast component of nystagmus is controlled by the hemispheres

54
Q

How is nystagmus named?

A

Fast beat

55
Q

What controls the fast beat of nystagmus?

A

The hemispheres

56
Q

There is not fast component of nystagmus when?

A

In the comatose patient

57
Q

Does the COWS mnemonic apply to the comatose patient?

A

NO-It is OPPOSITE

58
Q

What is decorticate posturing? What does this indicate?

A

Bilateral flexion at the elbows and wrists with extension of the lower extremities

Lesion is above the brainstem

59
Q

What is decerebrate posturing? What does this indicate?

A

Bilateral extension of the elbows with extension of the lower extremities

Usually bilateral or midbrain pontine

60
Q

What is myoclonic jerking?

A

Non-rhythmic movement d/t metabolic causes

61
Q

What is rhythmic myoclonus?

A

Brainstem issues

62
Q

True or false: the plantar reflex may be extensor in coma for any reason

A

True

63
Q

True or false:Most patients with absent cortical or brainstem function will have some form of spinal reflex

A

True

64
Q

Which generally has a rapid, and which a slow onset: structural / metabolic causes of a coma?

A 
Structural = rapid
Metabolic = slow
65
Q

What are the respirations like with metabolic problems?

A

Deep, frequent

66
Q

What are the three major non-structural causes of coma?

A

Toxins
Metabolic
Infectious

67
Q

What are the PE signs of head trauma?

A
  • Racoon eyes
  • Battle signs
  • Hemotympanum
  • Rhinorrhea or otorrhea (with CSF)
68
Q

Where is the major breathing center in the brain?

A

Medulla and Pons

69
Q

What are the pupil characteristics of opioid use?

A

Pinpoint

70
Q

What is the role of the vestibulo-oculogyric reflex testing?

A

Confirm or refute a negative Doll’s eye maneuver

71
Q

In the comatose patient, putting cold water in the right ear will cause the eyes to deviate what direction?

A

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
Q

Asymmetry with eye movements indicates a metabolic or structural problem?

A

Structural

73
Q

What is the reversal agent for opioids?

A

Naloxone

74
Q

What is the reversal agent for Benzos?

A

Flumazenil

Neurology (23 decks)

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