Coma Lecture Powerpoint

Question 1

Consciousness definition

Answer 1

State of awareness of self and environment, condition for which a person is capable of perceiving stimuli from the environment and respond appropriately, components include arousal (being awake mediated by reticular activating system) and awareness to sensations, emotions, and thoughts around us

Question 2

System of consciousness has 2 principle functions

Answer 2

1) maintenance of waking state (arousal)

2) content of experience (awareness)

Question 3

Components of “normal” waking consciousness (8)

Answer 3

• level of awareness
• content limitations
• attention
• controlled and automatic processes
• Perceptual and cognitive distortions
• emotional awareness
• self control
• time orientation

Question 4

Clouding of consciousness

Answer 4

Very mild form of altered mental status in which patient has inattention and reduced wakefulness

Question 5

Confusional state

Answer 5

More profound consciousness deficit that includes disorientation, bewilderment, and difficulty following commands

Question 6

Delirium

Answer 6

An acute confusional state characterized by alternation of consciousness with reduced ability to focus, sustain, or shift attention

Question 7

Drowsiness

Answer 7

State of consciousness where a person can be aroused by moderate stimuli but then drifts back to sleep

Question 8

Lethargy

Answer 8

A state of consciousness of severe drowsiness in which a patient can be aroused by moderate stimuli with drowsiness between sleep states and then drifts back to sleep

Question 9

Obtundation

Answer 9

A state of consciousness similar to lethargy where patient has lessened interest in environment*** and slowed response to stimulation, tending to sleep more than normal with drowsiness between sleep states

Question 10

Stupor

Answer 10

State of consciousness where only vigorous and intense stimuli will arouse and individual, but when left undisturbed immediately relapse into unresponsive state

Question 11

Coma

Answer 11

State of unarousable unresponsiveness

Question 12

Minimially conscious state and an example

Answer 12

State related to coma with minimal but definite behavioral evidence of self or environmental awareness, with partial preservation of consciousness ex) following commands such as looking up or down

Question 13

Vegetative state and example

Answer 13

State relating to coma where patient is able to be aroused but not aware** ex) Terri Schiavo case

Question 14

Brain death

Answer 14

State related to coma considered death by neurological criteria, absence of brain stem reflexes, EEG showing no electrocerebral activity, may be kept alive by medical needs but even involuntary actions need to be performed by external influence

Question 15

Ascending reticular activating system (ARAS)

Answer 15

Basic network of neurons originating in upper pons and midbrain integral to introducing and maintaining arousal, neurons project to diencephalon (thalamus and hypothalamus) and then to the cerebral cortex integral to awareness

Question 16

5 causes of coma

Answer 16

• herniation syndrome and various trauma
• structural or brainstem lesions
• metabolic causes
• toxic syndromes (drug overdose)
• infection

Question 17

Decorticate posturing, what its glasgow coma scale is, and what it indicates (3)

Answer 17

Presentation of stiff bent arms towards body and clenched fists with fingers bend and held on the chest with legs straight out (glasgow coma scale 3 in motor), indicating damage to cerebral hemispheres, midbrain, or thalamus

Question 18

Decerebrate posturing what its glasgow coma scale is, and what it indicates (4)

Answer 18

Presentation of arms and legs held out straight, toes pointed downward, head and neck arched backwards, muscles tightened and held in rigidity (Glasgow coma scale 2 in motor), indicating brain stem damage, lesions or compression of midbrain, or lesions of cerebellum

Question 19

Decerebrate posturing is often seen in ___ strokes

Answer 19

pontine

Question 20

Common causes of metabolic induced coma and what is the most common? (11 of em, just list a few for christ sake)

Answer 20

• Hypoxia (most common)
• hypoglycemia
• hyperglycemia
• hypothyroidism
• CNS infection
• drugs
• hyperkalemia
• hyponatremia
• uremia
• hypocalcemia
• anemia

Question 21

Asterixis

Answer 21

Tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings, characterized by an inability to maintain a position upon manipulation by practitioner in already extended state (wave goodbye sign)

Question 22

myoclonus and what is multifocal myoclonus suggestive of?

Answer 22

• Quick involuntary muscle jerk (hyperreflexia) characterized by practitioner pushing back on neutral state wrist or ankle and seeing jerking movement
• multifocal is strongly suggestive of metabolic coma

Question 23

Pupils and vital signs with the various toxidromes (sympathomimetic, anticholinergic, hallucinogenic, opioid, sedative, cholinergic, serotonin syndrome)

Answer 23

Sympathomimetic - mydriasis and elevations and hyperactive bowel sounds
Anticholinergic - mydriasis and elevations
Hallucinogenic - mydriasis and elevations and hyperactive bowel sounds
Opioid - Miosis and depressions
Sedative - Miosis and depressions
Cholinergic - miosis and depressions but hyperactive bowel
Serotonin syndrome - Mydriasis and elevations

Question 24

Common causes of infectious coma (4)

Answer 24

• Bacterial meningitis
• viral encephalitis
• syphilis
• malaria

Question 25

Waterhouse-friderichsen syndrome

Answer 25

Adrenal failure due to bleeding into the adrenal glands most often infectious in origin caused by neisseria meningitidis

Question 26

How does locked in syndrome differ from coma?

Answer 26

Consciousness is preserved even though patient cannot move muscles they can voluntary blink and move vertical eyes, can still perceive and detect the environment

Question 27

How does Akinetic mutism differ from coma?

Answer 27

A lack of motor response in awake individual where a patient cannot move or speak

Question 28

How does Psychogenic unresponsiveness differ from coma?

Answer 28

It is a prolonged motionless dissociative attack with absent or reduced response to external stimuli despite no activity cessation on an EEG, likely in response to trauma

Question 29

Initial evaluation and history of suspected coma patient (6)

Answer 29

- history from witnesses - old charts or medical bracelets - abrupt, gradual, or fluctuating? - preceding focal signs and symptoms (transient visual symptoms indicate ischemia!)? - recent illness? - drug use/abuse?

Question 30

Cherry red skin in suspected coma patient is associated with...

Answer 30

...carbon monoxide poisoning

Question 31

Osler's nodes

Answer 31

Painful purple nodules on palms and soles seen in bacterial endocarditis

Question 32

Neurologic exam on a suspected coma patient

Answer 32

- Level of consciousness: (Glasgow coma scale) - Motor responses (muscle tone, reflexes, posturing) - Brainstem reflexes (pupillary light, corneal reflexes)

Question 33

Glasgow coma scale does not include ____ in coma assessment while FOUR score does making it slightly better

Answer 33

Brainstem reflexes

Question 34

Glasgow coma scale definition and ranges

Answer 34

Grades severity of coma according to 3 categories of responsiveness excluding the brainstem, with a score of 3 being worst and 15 being best, 13 or higher indicates mild brain injury, 9-12 indicates moderate, 8 or less is severe

Question 35

FOUR score definition and ranges

Answer 35

4 component exam to grade severity of coma, including eye, motor, brainstem**, and respiratory, lower the score the greater the severity of coma, has better biostatistical properties than glasgow coma scale in terms of sensitivity, specificity, accuracy, and positive predictive value

Question 36

FOUR score <6 predicts...

Answer 36

....expected death

Question 37

Pinpoint pupils is indicative of ____, significant asymmetric pupillary response is indicative of ____ or ___, unreactive midsized pupils indicates ___ or ___

Answer 37

Pontine lesion, brainstem involvement, ruptured aneurysm, drugs, death

Question 38

Vestibule-ocular reflex

Answer 38

Detects an intact brainstem, if when turning patients head, eyes remain facing forward, they have an intact brainstem, but if eye turns with the head then brainstem is damaged

Question 39

Caloric reflex test

Answer 39

Intact brainstem reflex test, cold water placed in the ear causes eyes to move toward the same ear in normal response, warm water placed in the ear causes the eyes to move away from the ear in normal response

Question 40

Things to give in suspected coma patient (4), things to order in suspected coma patient (6)

Answer 40

- Glucose IV - thiamine - naloxone (counteract narcotic OD) - O2 - Non contrast CT - EKG - TSH - CBC - blood culture - EEG

Question 41

Lumbar puncture is indicated if these 2 things are present (suspicion of meningitis)

Answer 41

- elevated or depressed temp | - nuchal rigidity

Question 42

Status epilepticus abortion drug choices in order of first choice to third

Answer 42

- IV lorazepam - IV dilantin or valproic acid - IV phenobarbital

Question 43

Confirmatory test for brain death

Answer 43

Blood flow perfusion on MR scintigraphy

Question 44

Cardinal feature of metabolic coma

Answer 44

-symmetrical nature of neurologic deficits, such as symmetric pupils that appear abnormal but constrict with light

Question 45

Glasgow coma scale criteria

Answer 45

- Eye opening (1-4) (4 is spontaneous) - Best verbal response (1-5) (5 is oriented) - Best motor response (1-6) (6 is obeys commands)