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Neurology > Coma/Raised ICP > Flashcards

Coma/Raised ICP Flashcards

0
Q

Four main causes of coma

A

Supratentorial mass lesions
Infratentorial mass lesions
Metabolic encephalopathy
Psychogenic coma

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1
Q

What is needed to maintain consciousness?

A

One cerebral hemisphere and the brain stem RAS (failure of both hemispheres OR the brain stem RAS results in coma)

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2
Q

How can you try to reverse coma (3 reversible etiologies)

A

Naloxone
Thiamine
Dextrose

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3
Q

Decorticate posturing

A

Upper extremity flexion, lower extremity extension

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4
Q

Decerebrate posturing

A

Extension of all four limbs

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5
Q

Does flexion or extension imply higher level of brain functioning?

A

Flexion

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6
Q

Verbal responses in Glasgow Coma Scale

A 
Oriented 5
Confused 4
Inappropriate words/ not coherent 3
No words, only sounds 2
None 1
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7
Q

Eye Opening in Glasgow Coma Scale

A

Spontaneously 4
To speech 3
To pain 2
None 1

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8
Q

Motor responses in Glasgow Coma Scale

A 
Obeys commands 6
Localizes to pain 5
Withdraws to pain 4
Abnormal flexion 3
Abnormal extension (decerebrate) 2
None 1
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9
Q

Dose of thiamine that should be given in comatose pt who is receiving glucose?

A

100 mg IV

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10
Q

What do pupils look like in coma due to metabolic reason?

A

Small and reactive

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11
Q

What do pupils look like in coma due to a tectal lesion

A

Large, fixed, hippus

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12
Q

What do pupils look like in coma due to lesion in pons

A

Pinpoint pupils

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13
Q

What do pupils look like in coma due to a midbrain lesion

A

Mid position, fixed

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14
Q

What do pupils look like in coma due to CN III (uncal) lesion

A

Dilated, fixed

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15
Q

What do pupils look like in coma due to diencephalic lesion

A

Small and reactive

16
Q

Vestibulo-ocular reflex (dolls eye reflex)

A

Reflex eye mvmt that stabilizes the image on the retina during head movements, such that eye moves in direction opposite to head movement in order to keep image in centre of retina - mediated by CN VIII and CN 3,4,6

17
Q

What are the brainstem reflexes to check in comatose pt

A 
Pupillary reflex
Corneal reflex
VOR dolls eye 
Caloric testing
Gag reflex
18
Q

In comatose pt, if you find asymmetric focal signs in CN exam what is next step in diagnosis and what do you suspect?

A

Order urgent non contrast head CT

- suspect structural cause of decreased consciousness such as stroke, abscess, tumor or ICH

19
Q

Cerebral perfusion pressure

A

CPP = MAP - ICP

- normally > 60 torr

20
Q

What cerebral perfusion pressure is considered “too low” and results in inadequate cerebral blood flow

A

< 40 torr

21
Q

Uncal herniation

A

Ipsilateral CN III palsy

Contralateral hemiparesis

22
Q

Central (transtentorial) herniation

A

Progressive rostral-caudal loss of brain stem function due to pressure on entire brain stem

23
Q

Transfalx (subfalcial) herniation

A

May cause infarction of anterior cerebral artery that lies in interhemispheric fissure

24
Q

Cerebellar tonsillar herniation

A

Compression of the medulla by the cerebellar tonsils

25
Q

Physical exam findings in pt with ICP

A

Altered mental status
Headache
Papilledema - hallmark but rare
Cushing reflex

26
Q

Cushing reflex

A

Elevated systemic BP with bradycardia - seen in setting of increased ICP; seen when the pressure is transmitted to the medullary autonomic centres

27
Q

what is a false localizing sign seen in pts with diffusely elevated ICP

A

CN 6 palsy

- paralysis of lateral gaze

28
Q

Diagnostic study of choice for raised ICP

A

Head CT

29
Q

What position should pt be placed in if they have raised ICP

A

Head and neck elevated at 30 degrees

30
Q

Hyperventilation as tx of increased ICP

A

Tracheal intubation to lower pco2 to 25-30 torr

- works within minutes by causing vasoconstriction of cerebral blood vessels but the effect only lasts 8 hours

31
Q

Mannitol as tx for increased ICP

A

Osmotic diuretic, dose 1/2 to 1 g/kg IV, repeat every 4-6 hours
- acts within minutes but do not exceed 325 mOsm

32
Q

Dexamethasone as tx for increased ICP

A

10 mg IV initially, then 4 mg every 4-6 hrs
- stabilizes vascular membranes and prevents vasogenic brain edema; acts within 24 hours and is only helpful if brain edema is due to expanding mass lesion

33
Q

Barbiturate therapy in tx of ICP

A

325 mg/kg

- reduces cerebral blood flow and intracranial pressure by decreasing the cerebral metabolic rate

Neurology (15 decks)

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