COMA AND RELATED DO

Question 1

denotes an inability to think with customary speed, clarity,

and coherence

Answer 1

CONFUSION

Question 2

This state also
implies a degree of imperceptiveness and distractibility,
referred to traditionally as _______

Answer 2

“clouding of the sensorium

Question 3

A confusional state can also accompany focal cerebral
disease in various locations, particularly in the__________ or result from disorders that disturb mainly
language, memory, or visuospatial orientation

Answer 3

right

hemisphere,

Question 4

the temporary storage of the solution of

one task for use in the next.

Answer 4

“working memory

Question 5

next. A deficit in working memory,
which is such a common feature of the confusional states,
can be demonstrated by_______

Answer 5

tests of serial subtraction, and

the spelling of words (or repeating a phone number)

Question 6

It tends to be least pronounced in the morning
and increases as the day wears on, peaking in the
early evening hours _________ when the patient is
fatigued, and environmental cues are not as clear

Answer 6

(“sundowning”)

Question 7

_______ denotes an inability to sustain a

wakeful state without the application of external stimuli

Answer 7

Drowsiness

Question 8

As a rule, some degree of_________
are coupled with drowsiness, both improving
with arousal

Answer 8

inattentiveness and mild confusion

Question 9

________ describes a state in which the patient can
be roused only by vigorous and repeated stimuli and
in which arousal cannot be sustained without repeated
stimulation.

Answer 9

Stupor

Question 10

In stupor

__________ is common, and there is a
reduction or elimination of the natural shifting of body
positions

Answer 10

Restless or stereotyped motor activity

Question 11

In stupor

_______ and the breathing
pattern may or may not be altered

Answer 11

Tendon and plantar reflexes,

Question 12

In psychiatry, the term _________`has been used in a second
sense-to denote an uncommon condition in which the
perception of sensory stimuli is presumably normal but
activity is suspended and motor activity is profoundly
diminished

Answer 12

stupor

Question 13

The patient who i s incapable o f being aroused b y external

stimuli or inner need, is in a state of _______

Answer 13

coma

Question 14

In lighter stages, sometimes
referred to by the ambiguous terms ____________
most of the above reflexes can be elicited, and the
plantar reflexes may be either flexor or extensor

Answer 14

semicoma or obtundation,

Question 15

similarities of sleep and stupor

Answer 15

These include yawning, closure of the eyelids, cessation
of blinking and reduction in swallowing, upward
deviation or divergence or roving movements of the
eyes, loss of muscular tone, decrease or loss of tendon
reflexes, and even the presence of Babinski signs and
irregular respirations, sometimes Cheyne-Stokes in type

Question 16

One sign of the
vegetative state is a lack of consistent__________ of
objects

Answer 16

visual following

Question 17

EEG patterns of PVS

Answer 17

low amplitude delta-frequency background activity,

burst suppression, widespread alpha and theta activity,

alpha coma pattern, and sleep spindles

Question 18

In the initial days and weeks, this syndrome of
unconscious awakening has been referred to as the vegetative state and, if lasting ______after nontraumatic
and _________ after traumatic injury, the syndrome has
been termed the persistent vegetative state

Answer 18

3 months

12 months

Question 19

The most common pathologic bases of this state are
_________as a result of closed head trauma,
widespread__________ after cardiac arrest, and thalamic necrosis from a number of causes

Answer 19

diffuse cerebral injury

necrosis of the cortex

Question 20

PVS is a state in which the cortex
is either diffusely injured or effectively disconnected and
isolated from the __________ or the thalamic nuclei are
destroyed.

Answer 20

thalamus,

Question 21

The vegetative state or the minimally conscious state
described further on, may also be the terminal phase
of progressive cortical degenerative processes such as
_________

Answer 21

Alzheimer and Creutzfeldt-Jakob disease

Question 22

the profound and widespread
dysfunction of the cerebrum is reflected by
extreme reductions in cerebral blood flow and metabolism,
measured with _________

Answer 22

positron emission tomography

PET

Question 23

____________ as

necessary for integrated consciousness

Answer 23

posterior parietal regions

Question 24

preserved autonomic and respiratory
function without cognition include \_\_\_\_\_\_\_\_ and
\_\_\_\_\_\_\_\_\_\_\_

Answer 24

apallic syndrome

neocortical death

Question 25

A study by the Multi-Society Task Force on PVS concluded
that the outcome from a vegetative state is better in
________

Answer 25

traumatic as compared to nontraumatic cases

Question 26

In minimally conscious state,

improve function by stimulating
the ___________ through
implanted electrodes in a patient who had been initially
vegetative and made a natural transition to a minimally
conscious state after traumatic brain injury

Answer 26

medial (interlaminar) thalamic nuclei

Question 27

there is little or no disturbance of consciousness, but

only an inability of the patient to respond adequately

Answer 27

locked in syndrome

Question 28

other term for locked in syndrome

Answer 28

deefferented state or pseudocoma

Question 29

a condition in which the patient is awake but was unresponsive
(actually their patient was able to answer in whispered
monosyllables).

Answer 29

akinetic mutism

Question 30

This state of apparent vigilance in an imperceptive
and unresponsive patient has been referred to by
French authors as ________

Answer 30

coma vigile

Question 31

The term akinetic mutism has been applied to yet
another group of patients who are silent and inert as a
result of bilateral lesions usually of the ____________ leaving intact the motor and sensory
pathways; the patient is profoundly apathetic, lacking to
an extreme degree the psychic drive or impulse to action

Answer 31

anterior parts of the frontal lobes,

Question 32

The patient with ________appears unresponsive, in
a state that simulates stupor, light coma, or akinetic
mutism BUT there is no structural brain abnormality

Answer 32

catatonia

Question 33

In catatonia, there is also the retention for a long period

of seemingly uncomfortable limb postures _________

Answer 33

(catalepsy).

Question 34

The central considerations in the diagnosis of brain

death are :

Answer 34

(1) absence of all cerebral functions;
(2) absence of all brainstem functions, including spontaneous respiration; and
(3) irreversibility of the state

Question 35

in brain death

The absence of brainstem function is judged by
the:

Answer 35

loss of spontaneous eye movements, midposition
of the eyes, and lack of response to oculocephalic and
caloric (oculovestibular) testing; the presence of dilated
or midposition fixed pupils (not smaller than 3 mm);
paralysis of bulbar musculature (no facial movement or
gag, cough, corneal, or sucking reflexes); an absence of
motor and autonomic responses to noxious stimuli; and
absence of respiratory movements

Question 36

Steps for apnea test

Answer 36

1. employing preoxygenation for several minutes
2. The patient can then be disconnected
   from the respirator for several minutes during
   which time 100 percent oxygen is being delivered by
   cannula or ventilator that has its pumping mechanism
   turned off

Question 37

Purpose of pre-oxygenation in apnea test

Answer 37

the purpose of which is to displace nitrogen from the alveoli and create a reservoir of oxygen that will diffuse along a gradient into the pulmonary circulation

Question 38

what happens if you remove the respiratot in apnea test

Answer 38

this allows the arterial Pco2 to rise to 50 to 60
mm Hg (typically, C02 rises approximately 2.5 mm Hg
per minute at normal body temperature-slower if the
patient is hypothermic

Question 39

The hypercarbia serves both as a ________and a confirmation that spontaneous
ventilation has failed.

Answer 39

stimulus to breathing

Question 40

effects of the apnea test

Answer 40

hypotension, hypoxemia, cardiac arrhythmias,

and barotrauma

Question 41

In brain death

this condition leads inability to produce tachycardia in response to the injection of atropine; this reflects the loss of innervation of the heart by the medullary vagal neurons

Answer 41

DI

Question 42

EEG tracing for confirmation of brain death

Answer 42

isoelectric tracing

Question 43

__________ is
considered to be present if there is no electrical potential
of more than 2 m V during a 30-min recording except for
artifacts created by the ventilator, electrocardiograph,
and surrounding electrical devices

Answer 43

Electrocerebral silence

Question 44

Other ddx for reversible isoelectric tracing:

Answer 44

1. profound hypothermia
2. intoxication with sedative-hypnotic drugs
3. and immediately following cardiac arrest

Question 45

In brain death, testing.

If cardiac arrest was the
antecedent event, or the cause of neurologic damage is
unclear, or drug or alcohol intoxication could reasonably
have played a role in suppressing the brainstem reflexes,
it is advisable to wait about ________ before repeating the
testing and pronouncing the patient dead

Answer 45

24 h

Question 46

In brain death, testing.

The specificity of
radionuclide scanning is close to ________but there
is a self-referential aspect to this statement as the clinical
diagnosis has been used as a gold standard

Answer 46

100 percent

Question 47

TCD findings for brain death

Answer 47

brain death shows a to-and-fro,

pendelfluss blood-flow pattern in the basal vessels.

Question 48

the EEG may transiently show diffuse and variable alpha (8- to 12-Hz) activity, which may be mistaken for the physiologic alpha rhythm.

It is not monorhythrnic like normal alpha activity, and
displays no reactivity to sensory stimuli.

Answer 48

alpha coma

Question 49

Alpha coma is
usually associated with __________
and has a poor prognosis

Answer 49

pontine or diffuse cortical lesions

Question 50

In cases of intoxication with sedatives,

exemplified by barbiturates and diazepines,_________initially replaces normal rhythms

Answer 50

fast

(beta) activity

Question 51

Oxygen consumption of ___________ (approximately

half of normal) is incompatible with an alert state

Answer 51

2 mg/min/100 g

Question 52

Toxins in coma

in DM, ________are present in high concentration;

in uremia, there is probably an accumulation of dialyzable small molecular toxins, notably_________

Answer 52

acetone bodies (acetoacetic acid, P-hydroxybutyric acid,
and acetone) 

phenolic derivatives of the aromatic amino acids.

Question 53

In hepatic coma, elevation of blood
NH3 (ammonia) to______ levels corresponds
roughly to the level of coma

Answer 53

5 to 6 times normal

Question 54

Lactic acidosis may affect the
brain by lowering arterial blood pH to less than _____ The impairment of consciousness that accompanies pulmonary insufficiency is related mainly to ________

Answer 54

7.0.

hypercapnia

Question 55

In acute hyponatremia_________ of whatever cause, neuronal dysfunction is probably a result of the intracellular movement of water, leading to _______

Answer 55

(Na <120 mEq/L)

neuronal swelling and loss of potassium chloride from the cells

Question 56

In other types of seizures, in
which consciousness is interrupted from the very beginning, a _________has been postulated (centrencephalic
seizures of Penfield

Answer 56

diencephalic origin

Question 57

it
has been recognized that interactions with ligand-gated
ion channels, particularly __________and alterations in neurotransmitter function are a more likely mechanism of anesthesiainduced unconsciousness.

Answer 57

gamma-aminobutyric acid

(GABA)-A receptors

Question 58

Under the title of ____________ a
rare condition has been described in adult men who
displayed a prolonged state of deep sleepiness lasting
from hours to days intermittently over a period
of many years

Answer 58

idiopathic recurring stupor,

Question 59

In idiopathic recurring stupor, During the bouts,
a 1 00 fold increase of circulating_______ an
ostensibly naturally occurring diazepine agonist,

Answer 59

endozepine-4,

Question 60

the cerebral peduncle, is pushed against the opposite
free edge of the tentorium (the resulting creasing of the
lateral edge of the peduncle is called the ______

Answer 60

Kernahan notch

Question 61

This causes weakness and a Babinski sign ipsilateral to

the hemispheral lesion and later, extensor posturing on that side

Answer 61

Kernahan- Woltman phenomenon

Question 62

coma; medium-sized fixed pupils that are referable to midbrain damage; bilateral decerebrate postures; loss of vestibuloocular (caloric, oculovestibular) responses all of which are the result of pontine damage; irregular breathing patterns that implicate medullary destruction; and death.

Answer 62

central syndrome with rostro-caudal progression

Question 63

drowsiness in the early stages is accompanied or
preceded by unilateral pupillary dilatation, most often
on the side of the mass, as a result of compression of the
third nerve

Answer 63

uncal syndrome

Question 64

Chronic administration
of _______ for hypertension can induce
stupor from cyanide toxicity.

Answer 64

nitroprusside

Question 65

________is observed in
patients with alcohol or barbiturate intoxication, drowning,
exposure to cold, peripheral circulatory failure,
advanced tuberculous meningitis, and myxedema

Answer 65

Hypothermia

Question 66

Sl0w breathing points to ________
and occasionally to hypothyroidism,

whereas deep, __________should suggest the presence of pneumonia, diabetic or uremic acidosis,
pulmonary edema, or the less-common occurrence of an
intracranial disease that causes central neurogenic hyperventilation

Answer 66

opiate or barbiturate intoxication

rapid breathing (Kussmaul respiration)

Question 67

Diseases that elevate intracranial pressure or

damage the brain often cause slow, irregular, or __________

Answer 67

cyclic

Cheyne-Stokes respiration

Question 68

Cherry-red coloration is typical of _______

Answer 68

carbon

monoxide poisoning

Question 69

Telangiectases and hyperemia of
the face and conjunctivae are the common stigmata of
______

Answer 69

alcoholism;

Question 70

_______ imparts a characteristic puffiness
of the face, and hypopituitarism an equally characteristic
_______complexion

Answer 70

myxedema

sallow

Question 71

Thrombotic thrombocytopenic purpura (TIP), disseminated
intravascular coagulation, and fat embolism may
cause _________

Answer 71

diffuse petechiae or purpura

Question 72

The spoiled-fruit
odor of _______, the uriniferous odor of uremia, the musky and slightly fecal fetor of _______,
and the burnt almond odor of ________

Answer 72

diabetic ketoacidotic coma

hepatic coma

cyanide poisoning

Question 73

A loss of

______usually precedes enlargement of the pupil

Answer 73

light reaction

Question 74

As a transitional phenomenon, the pupil may become
oval or pear-shaped or appear to be off center (corectopia)
because of a _______

Answer 74

differential loss of innervation of a

portion of the pupillary sphincter

Question 75

The ipsilateral pupillary dilatation from

pinching the side of the neck (the ciliospinal reflex) is usually lost in _______

Answer 75

brainstem lesions

Question 76

Systemic poisoning with ____ or with drugs
that have atropinic qualities, especially the _______
is characterized by wide dilatation and fixity
of the pupils

Answer 76

atropine

tricyclic antidepressants,

Question 77

Hippus, or fluctuating pupillary size, is

occasionally characteristic of _______

Answer 77

metabolic encephalopathy

Question 78

“Wrong-way eyes” a paradoxical conjugate
deviation to the side opposite the lesion may sometimes
occur with _____

Answer 78

thalamic and upper brainstem lesions

Question 79

_________in
which the eyes move down slowly and return rapidly to
the meridian, is observed with coma caused by anoxia
and drug intoxications;

Answer 79

“Ocular dipping,”

Question 80

In OCM, The response in coma

of metabolic origin or that caused by bihemispheric structural lesions consists of

Answer 80

conjugate movement of the eyes in

the opposite direction

Question 81

Elicitation of these ocular reflexes

in a comatose patient provides two pieces of information:

Answer 81

(1) evidence of unimpeded function of the midbrain and
pontine tegmental structures that integrate ocular movements and of the oculomotor nerves, and

(2) loss of the
cortical inhibition that normally holds these movements in
check.

Question 82

Irrigation of one ear with 10 mL of cold water (or
room-temperature water if the patient is arousable)
causes slow conjugate deviation of the eyes__________ followed in a few seconds by _______

Answer 82

toward the irrigated ear,

compensatory
nystagmus

Question 83

periods
of waxing and waning hyperpnea alternating with a
shorter period of apnea

Answer 83

Cheyne-Stokes respiration

Question 84

The more conspicuous
respiratory arrhythmias are associated with lesions b____________ and are therefore
found in the late stages of brainstem compression
or with destructive brainstem lesions

Answer 84

below

the level of the reticular-activating system

Question 85

Lesions of the lower midbrain-upper pontine tegmentum,
either primary or secondary to transtentorial
herniation, may give rise to _______

Answer 85

central neurogenic hyperventilation

CNH

Question 86

This disorder is characterized by an
increase in the rate and depth of respiration to an extent
that produces advanced respiratory alkalosis

Answer 86

central neurogenic hyperventilation

CNH

Question 87

Low pontine lesions, usually caused b y basilar artery
occlusion, sometimes cause __________ (a pause of
2 to 3 s in full inspiration) or so-called short-cycle CheyneStokes respiration, in which a few rapid deep breaths alternate with apneic cycles

Answer 87

apneustic breathing

Question 88

With lesions of the dorsomedial
part of the medulla, the rhythm of breathing is chaotic,
being irregularly interrupted and each breath varying
in rate and depth ______

Answer 88

(Biot breathing; also called “ataxia of

breathing”).

Question 89

In regard to all forms of
coma, but particularly after cardiac arrest, if there are no
pupillary, corneal, or oculovestibular responses within
_____________, the chances of regaining independent
function are practically nil

Answer 89

1 day of the onset of coma

Question 90

Other signs that predict a poor outcome are _________

Answer 90

absence of corneal reflexes, eye-opening responses, atonia of the limbs at
1 and 3 days after the onset of coma, and absence of
the cortical component of the somatosensory-evoked
responses on both sides