Coma & Delirium Flashcards
what are the 2 major components of consciousness?
awareness/content
what is the diff betw Awareness and Arousal?
Awareness = higher cortical functions are intact, language as one of its facets, movements are appropriate & localized
Arousal = reflexes, groaning, flexion-extension, eye-opening
what are the different acutely altered states of consciousness?
confusion
delirium
obtundation
stupor
coma
what is the general incapacity of a patient to think with customary speed, clarityu and coherence?
confusion
what is the misperception of stimuli and vivid hallucinations, agitation, tremulousness?
delirium
what is the slow response to stimulation with mild to moderate reduction in alertness?
obtundation
what is the behavioral unresponsiveness and is arousable only by vigorous stimualtion?
stupor
whta is the state of unresponsiveness even to vigorous stimulation
coma
what are the diff subacute/chronic atlerations of consciousness?
dementia
akinetic mutism
minimally conscious state
vegetative state
what type of alteration of consciousness involves limited responsiveness to primitive postural or reflexive movement of the limbs?
vegetative state
what type of alteration of consciousness involves “transitional state” during recovery from coma or worsening of a progressive neurologic disease?
minimally conscious state
what type of alteration of consciousness involves condition of silent, alert-appearing immobility wherein sleep-wake cycles have returned?
akinetic mutism
what type of alteration of consciousness involves enduring and often progressive decline in mental processes?
dementia
what condition occurs if there is a pontine lesion, every motor function is obliterated, patient is unconscious, and eye movement in the only motor function intact?
Locked-in syndrome
what are the diff aspects of behavior are affected in delirium?
attention
perception
memory
thinking
emotion, mood & affect
impulse & activity
social behavior
loss of insight
what are the different classificatio of confusional stateS?
Acute global confusion with psychomotor underactivity
Delirium with motor, mental, or autonomic hyperactivity
psychosis, particularly with manic features
Dementia or other brain disease
What are the causes of acute global confusion w/ psychomotor underactivity?
Metabolic disorders
Infectious illnesses
CHF or pulmonary failure
Postoperative & post-traumatic states
What are the common causes of delirium?
- Alcohol withdrawal
- Medications
- Beclouded dementia = baseline dementia + other medical/surgical problem
- Infection/post-operative states
- Non-convulsive status epilepticus
- Schizophrenia, bipolar psychosis during a medical or surgical illness
What are the signs of meningeal irritation?
Treat the underyling cause of infection
Systemic infection
Meningitis and encephalitis = lumbar puncture
What are the dx tests done in px with focal neurologic signs or seizure?
Overt seizure
Neuroimaging and EEG
In px with delirium, do u still need to do an urgent neuroimaging scan if there is no focal sign on exmination?
No need but if you think your px is high-risk fr a vascular CNS event, then proceed with neuroimaging
How do you classify and diagnose coma?
- Is the coma neurologic or non-neurologic?
- Are there focal, lateralizing signs?
If there are focal lateralizing signs, what should u do next?
Brain imaging
(CN deficits, hemiparesis, Babinski sign)
If the cause of coma is non-focal in exam what should u do?
Basic work-up (blood chem, ABG, infectious work up_
(No focal, lateralizing signs)
What happens if lab tests come out as negatieve, what should u do?
Neuroimaging = CT/MRI/LP/EEG
What should u do if there is high suspicion for seiure & CNS infection?
Seizure = do EEG
CNS infection = do a lumbar puncture
What are structures in the brain that can cause coma when affected bILATERALLY?
Medial hemispheric wall including the basal forebrain
Caudate and putamen (striatum)
Diencephalon
Midbrain tegmentum and rostral pontine tegmentum
What are brain lesions that can cause coma?
- diffuse hemispheric damage
- injury of diencephalon
- damage to the paramedian portion of the upper midbrain and caudal diencephalon
- high pontine or paramedian lower midbrain injury
What condition ha a space occupying lesion or mass causing herniation across diffferent dural compartments?
Herniation syndrome
What are the diff causes of herniation syndrome?
- transfacial herniation
- transtentorial uncal-parahippocampal
- cerebellar tonsillar herniation
- Kernohan-Woltman notch phenomenon/horizontal herniation
What are the common causes of coma with focal or lateralizing signs?
Cerebral hemorrhage
Basilar artery occlusion
Territorial infarction in internal carotid artery
Subdural hematoma
Trauma
Brain abscess
Hypertensive encephalopathy; Eclampsia
THrombotic thrombocytopenic purpura
What are the diff disorders assoc with coma without focal or lateralizing signs bUT WITH signs of meningeal irritation?
Meningitis and encephalitis
Subarachnoid hemorrhage
In px with coma without focal neurologic signs or meningeal irritation, when do you order a lumbar puncture?
If everything else is ruled out (no infection, normal blood chem, MRI, EEG) but px is still in a coma
What is the most common cause of coma without focal neurologic signs or meningeal irritation, CSF & CT scan normal?
Alcohol intoxication
What are the 3 facets checked in the Glasgow coma scale?
Eye response
Motor response
Verbal response
What are the interpretation of GC scores?
> or equal to 13 = mild brain injury
9-12 = moderate brain injury
< or equal to 8 = severe brain injury
What should u do if GCS less than or equal to 8?
Intubate the px & protect the airway
What is the normal size of the pupil?
2-3mm
What is the single most important test to distinguish a metabolic cause for coma vs neurologic ause?
Pupillary light reflex
What are the indications of unilateral deficient pupil and bilaterally reactive pupil?
- Unilateral deficient pupil
- focal lateralizing sign
- if structural => neurologic problem - Bilaterally reactive pupil
- metabolic cause
- medical, not structural then not neurologic
What is the localization of lesion of Uncal Herniation (CN III) and midbrain?
Uncal herniation (CN III)
- unilateral dilated pupil
- fixed
Midbrain
- midposition
- fixed
What is the localization of lesion for lesions on the Pons & Diencephalon?
Pons
- pinpoint, but not reactive
- narcotic intoxication
Diencephalon
- small, reactive
What are pupil reaction if lesion is at teh pretectal or diffuse effects of drugs, metabolic encephalopathy?
Pretectal
- large, “fixed”, Hippus
Diffuse effects of drugs
- small, reactive
What are the most common spontaneous eye movements in unconscious px?
Ocular bobbing & ocular dipping or inverse ocular bobbing
What is the description & significance if there is ocular bobbing seen?
- rapid, conjugate, downward movement
- slow return to primary position
Significance
- pontine strokes
- other structural, metabolic, or toxic disorders
What is the description & significance if there is ocular dipping or inverse ocular bobbing seen?
- slow, donward movement
- RAPID return to primaryposiiton
- unreliable for localization & follows hYPOXIC-ISCHEMIC INSULT or metabolic disorder
What is the description & significance if there is reverse ocular bobbing seen?
- rapid, upward movement
- slow return to primary position
Unreliable for localization - may occur with metabolic disordes
What are the diff brainstem reflexes checked in coma px?
EOMs = Doll’s eye reflex
Caloric reflexes
Corneal reflexes
Gag reflex
What is done in caloric reflex?
Instillation of 120mL of ice water
Awake = deviation toward, nystagmus away
Comatose = deviation towards the side of cold water irrigation, away from side of warm water irrigatoin
What is the indication if there is absence of corneal reflexes?
Brainstem reflexes are diminished
What brainstem reflex is done usually if intubated?
Gag reflex
What are checked in the motor response of coma px?
Response to pain
Primitive reflexes
Posturing
What are the sites of repsonse to pain checking in motor response?
Supraorbital pressure
Fingernail bed pressure
Sternal rub
Pressure on both temples
What are the responses in posturing if ther eis metabolic encephalopahty or diffuse cortical dysfunction with no focal alteralizing signs?
Patient raises a hand in attempt to remove the hand othe examiner
(+) = localization of pain
What is the response in px with upper midbrain damage if posturing is ellicited?
DECORTICATE POSTURING = flexion of the upper extremities and EXTENSION of the LEs
What is the respone of upper pontine damage in posturing of coma px?
DECEREBRATE POSRUTING = Extension of both UE & LE
What aer the diff types of abnormal patterns of respiration seen in brain lesions?
Cheyne-stokes respiration
Central neurogenic hyperventilation
Apneustic breathing/apneusis
Cluster breathing & ataxic breathing
Apnea
