coma and brain death Flashcards
1
Q
2 most common causes of comma
A
- cardiac or pulmonary failure >5min
- drug/alcohol overdose
2
Q
other causes of coma
A
severe organ failure stroke or hemorrhage in CNS cranial trauma infections psychiatric pseudo-coma or catatonia (rare)
3
Q
oculocephalic reflex
A
‘dolls eyes’
eyes go in opposite direction of head turn
4
Q
oculovesticular reflex
A
cold water on ear drum- eye moves towards the stimulus with a nastagmus away
5
Q
2 most important prognostic indicators of coma
A
-pupillary rxns to light
-spontaneous mvmts
if these are absent for 72 hours and no known reversible cause, pt has <5% chance of survival
6
Q
requirements for brain death
A
no known reversible cause
no evidence of cerebral fnx
no evidence of brain stem fnx (loss of CN reflexes)
APNEA test
can do EEG or cerebral arteriography or radionuclide brain scans
7
Q
persistent vegetative state
A
vegetative state >1month
still have brainstem fnx, but NO Cx fnx
8
Q
alzheimers
A
most apparent in temporal and parietal lobes
drugs which lower amyloid do not help
9
Q
risks fo alzheimers
A
almost all cases >65yrs W>M poorly educated, mentally inactive head trauma homozygous for e4 allele of ApoE
10
Q
symptoms of alzheimers
A
almost always present w/loss of memory first
speech becomes restricted
visuspatial decline (get lost in familiar places)
depression
gait disorder
sundowning
11
Q
CSF in alzheimers
A
soluble beta amyloid low
tau high
12
Q
Tx of alzheimers
A
cholinesterase inhibitors
memantidine (blocks NMDAR)
anti-depressents
mentally and physically active
13
Q
cholinesterase inhibitors for alzheimers
A
relief of memory impairment, agitated behavior, poor concentration do not work for very long -donepexil -rivastigmine -galantamine
14
Q
mild cognitive impariment
A
pt who have limited problems w/memory or cognition
50% go on to develop alzheimers
15
Q
lewy body dementia
A
fluctuating dementia w/agitated behavior decreased facial animation slowness and imbalance mild or no tremor visiual hallucinations BAD response to antipsychotic drugs live 5-7yrs like parkinsons except early onset of dementia and agitations
16
Q
lewy bodies
A
contain alpha-synuclein
17
Q
multi-infarct disease
A
dementia d/t known Hx of strokes
seizures more common then w/other dementias
often have concurrent vascular disease
18
Q
fronto-temporal dementias
A
family of multiple disorders
increased Tau, TDP-43, Ubiquitin
typical onset 50-60
pick bodies
19
Q
fronto-temporal dementia behavior dominant form
A
most common major personality changes obsessions overeating/overdrinking occasional weakness, ataxia, clumsiness no auditory/visual hallucinations
20
Q
fronto-temporal dementia language predominante form
A
primary progressive expressive aphasia
21
Q
CJD
A
transmissible spongiform encephalopathy prominent myoclonic jerks loss of balance and coordination EEG triphasic waves high 14-3-3 in CSF
22
Q
normal pressure hydrocephalus symptoms
A
gait disturbances (wide)
incontinence (wet)
dementia (weird)
23
Q
normal pressure hydrocephalus Dx
A
removal of 30cc of CSF provides symptom relief
24
Q
normal pressure hydrocephalus Tx
A
ventriculo-peritoneal shunting
25
CV syncope
```
decreased CO
cardiac arrhythmias
aortic stenosis (elderly)
idiopathic subaortic hypertrophic cardiomyopathy (HS kids)
mitral valve prolapse (young women)
```
26
tonic phase of tonic-clonic seizure
clenching/tightening of mm in fixed position
arms flexed, legs extended
close mouth, open eyes
loss of urinary and sometimes bowel continence
27
clonic phase of tonic-clonic seizure
repetitive synchronous mvmts of arms and legs
28
physiologic changes during seizure
```
HR increases immediately
O2 saturation drops
BP increase
pupils dilate and do not react to light
metabolic acidosis
```
29
todds paralysis
rare
| pt remains weak on one side for a day after seizure
30
Imaging for HA
recurrent migraine do not need image unless: recent change in HA pattern, focal neuro signs
MRI more likely to show cause
31
Dx of migraines
>= 5 attacks lasting 4-72hrs
>= 2 of (u/l, pulsating, moderate/severe intensity, aggravation by physical activity)
>=1 of (nausea, photophobia, phonophobia)
no evidence of secondary HA
32
idiopathic intracranial HTN
```
aka pseudotumor cerebri
progressive diffuse HA w/intermittent loss of vision in 1 or both eyes
obese young women
papilledema
often have extraoccular palsy
```
33
Tx of idiopathic intracranial HTN
weight loss
steroids
carbonic anhydrase inhibitors
defenestration of optic nn sheath or lumbar-periotoneal shunt
34
triptans
serotonin agonists
rizatriptan
eletriptan
CI in known coronary artery or cerebral vascular disease
35
ergotamines
DHE
causes significant vasoconstriction and can increase BP
given w/caffeine
36
great prophylaxis of migraine
amitriptyline
propanolol
topiramate
37
amitriptypline
```
tricyclic antidepressent
low doses in evening
may cause tachyarrythmias
weight gain
have to worry about suicide potential
```
38
propanolol
long acting once daily
| relative CI in asthma, CHF, or bradycardia d/t heart block
39
topiramate
anticonvulsant
take at bedtime
may cause difficulties w/speech and cognition- nickname dopamax
weight loss, anorexia, loss of sensation in arms
40
good prophylaxis
gabapentin
| zonaisamide
41
fair prophylaxis
valproic acid
| verapamil
42
valproic acid
```
bad side effects
weight gain
lowering platelet count
tremor
hair loss
```
43
abortive Tx of cluster HA
sumatriptan injection or nasal spray
high dose O2
nasal lidocaine
44
preventative Tx of cluster HA
```
must use
verapamil
lithium
prednisone
deep brain stimulation
```
45
verapamil
CaCh blocker
may need high doses
ADR: hypotension and constipation
46
lithium
unclear effects on postsynpatic transmission
suicide potential
ADRs: renal and thyroid disease
47
prednisone
limited use d/t side effects
48
Tx of trigeminal neuraliga
carbamazepine
| surgical
49
MS epidemiology
mean onset 29
rare 55
70% women, men worse prognosis
north of equator
50
pathology of MS
```
T-cell mediated
do not know subtype of T cell
do not know Ag
do not know how T cells cross BBB
macros, cytokines, and chemokines are involved
```
51
benign MS
have infrequent minor attacks and always return to normal basline
52
relapsing remitting MS
most common
intermittent attacks that progressively get worse and more frequent
baseline progressively gets worse after each attack
53
secondary chronic progressive MS
second most common
| starts out like relapsing intermittent, but then just takes off as continuously degenerating disease
54
primary progressive MS
rare
never recover from 'first attack
and just keep getting worse
55
kurtzke's rule
90% of disabilities of MS occurs w/in first 10yrs
56
MS first attack symptoms
visual loss or double vision, most common, usually improves
weakness, usually improves
paresthesiaes, usually does not improve
depression can precede Dx by yrs
57
Dx of MS
multiple attacks in time and location
MRI
CSF
58
MRI of MS
9+ lesions
at least 1 gadolinium enhancing lesion
at least 1 lesion in cerebellum or brainstem
at least 3 periventricular lesions
59
CSF of MS
oligoclonal band in 90%
increased myelin basic protein or IgG index
increased WBC, but <100
60
optic neuritis
painful, sudden loss of vision usually u/l
pupillary light reflex usually lost -> marcus-gunn pupillary light reflex
50% develop MS
time to recovery shortened w/IV corticosteroids
61
internuclear opthalmoplegia (INO)
eyes cannot ADDuct, only ABduct
severe nystagmus
d/t damage of MLF
only two causes: MS or brainstem stoke
62
Tx of MS
beta interferons
glatiramer acetate
natalizumab
fingolimos
63
beta interferons
limit pathologic activity of MS
acenoz
beatseron
rebif
64
glatiramer acetate
only indicated for relapsing remitting MS
| may micic meylin protein acting as decoy
65
natalizumab
possibly most effective
| at risk for PML d/t JC virus
66
fingolimos
PO
limits circulation of lymphocytes fewer cross BBB
ADR: cardiac effects, coronary artery diseae
67
symptomatic Tx of MS
corticosteriods- during attack
antispasmoics
antidepressents
68
neuromyetlites optica/NMO
```
devics disease
optic neuritis (usually b/l) and spinal cord demyelination w/o brain demyelination
distinct from MS
seldom have oligoclonal bands
at risk for respiratory crisis
infants-90s
```
69
NMO MRI
show spinal cord lesions at 3+ levels
| usually severe w/cavitation and hemorrhage
70
pathology of NMO
Abs to aquaphorin 4 Chs
| can follow infection
71
Miller fishcer variant of GBS
limited leg and arm weakness
| opthalmoplegia and cerebellar deficits predominate
72
Dx of GBS
nerve conduction and electromyograms
| LP abnormal, but takes a week significant elevated protein
73
chronic inflammatory demyelinating polyneuropathy (CIPD)
slower form of polyneuropathy developing over 3-6months
milder weakness, more sensory complains
responds to corticosteroids (GBS does not)
can also use plasma exchange or IVIG
74
Tx of GBS
plasma exchange
| IVIG
75
benign paroxysmal postional vertigo (BPPV)
```
intermittent vertigo lasting <1min associated w/changes in head position
walking impaired, but possible
sometimes follows cold, URI, or trauma
full relief by lying still
lasts 1-2wks
```
76
pathology of BPPV
detachment of otolithic crystals
77
Dx of BPPV
clinical
no hearing loss
Dix-hallpike maneuver
78
Tx of BPPV
```
epley manuver
meclizine
scopolamine patch
promethazine
diazepam
```
79
Menieres disease
recurrent attacks over years/decades of vertigo, tinnitus, decline in hearing, pressure in ear
ultimately have hearing loss
completely immoblize pt
rare cochlear variatn w/prominent hearing loss and mild vertigo
80
pathology of menieres disease
increased volume of endolymphatic fluid -> bulges -> ruptures -> attack
mostly sporadic, rarely familial
81
Tx of menieres attack
meclizine
promethazine
scopolamine patch
82
prophylaxis of menieres attacks
low Na diet
K sparring diuretic
surgical repair
resolves in most pts eventually w/o surgery
83
cerebellar disease
ataxia
inability to walk/control direction
fall a lot
intention tremor
84
cerebellar stroke
```
sometimes few cerebellar symptoms seen
ataxia, dysmetria, nystagmus, dysarthria
vomiting
walking may be impossible
HA, diplopia
if not detected infarct grows -> closes of ventricles -> hydrocephalus -> herniation
```
85
glasgow coma scale
9-13 minor
8-12 moderate
7 and below major
86
cushing reflex
after head injury or growth of tumor pts have HTN and bradycardia
87
SDH
venous
cresent
acute if 33mm
cohen prefers craniotomy
88
EDH
```
less common
arterial
middle menigeal a
lucid interval
surgical drainage always required
```
89
concussions
must do CT if LOC, persistent HA, or neuro signs
90
post concussive syndrome
```
persistent HA
light headedness
depression
poor concentration
irritability
can last for wks-months
resistent to Tx
```
91
chronic traumatic encephalopathy
Tau build up, especially in temporal and frontal lobes
brain atrophy
damaged septum pallicidum and corpus collosum
do not have amyloid plaques
92
four cardinal features of parkinsons
resting tremor
bradykinesia
disequillibrium
rigidity
93
other signs and symptoms of parkinsons
```
sleep disorders
loss of sense of smell
autonomic problems
cramps/pains in back and shoulders
depression, dementia
smaller incomprehensible handwriting
loss of power of voice
```
94
parkinsons epidemiology
55-59yrs, but anywhere from 40-70
smokers, caffeine consumers lower incidence
rural areas
M>W
95
drug induced parkinsonism
```
usually do not have resting tremor
anti-cholinergics
phenothiazines
metoclopramide
promethazine
```
96
progressive supranuclear palsy
usually no tremor, but severe disequillibrium
falls and choking seen early
progressive loss of extraoccular mvmts
dystonic extension of neck, furrowed brow, look scarred
blink frequently
usually die from aspiration pneumonia or fall
live 5-6yrs
97
essential tremor
most common mvmt disorder seen in practice
older onset worse prognosis
rue out huperthyroidism, medication cause, cerebellar disease
98
essential tremor Tx
propranolol
primidone
deep brain stimuation
99
tourettes
likely associated w/OCD, ADHD, depression
| Tx w/haloperiodl or other D2 blockers
100
huntingtons
onset 40-50
| chorea limited by dompamine blockers
101
resteless leg syndrome
```
AR inheritence
Tx:
-pramipexole
-levodopa/carbidopa
-Fe
-benzodiazepines
-gabapentin
-opioids
```
102
MG
thymic tumors or hyperplasia common
nerve conduction studies shows decremental response
tensilon test
103
MG Tx
anticholinesterases
corticosteroids
plasmaphoreiss
IVIG
104
ALS
may present w/asymmetric weakness
no extraoccular eye mm involved
dysarthria most common early symptom
105
ALS presentatin
worsening weakness
frequent fasiculations
loss of speech, inability to move tongue, tongue atrophy
split hand w/ulnar sparing
cognitive decline in 105 (frontal lobe w/personality changes)
106
Dx ALS
EMG- denervation of 3+limbs
107
Tx of ALS
riluzole
