consciousness

Question 1

Consciousness requires a person to be ____ and ____of self and environment

Answer 1

awake aware

Question 2

Awake =
Awareness =
_____ and _____ are examples of FOCAL loss of awareness

Answer 2

arousal / level of alertness; ability to perceive stimuli in different domains;
aphasia and neglect

Question 3

there are 3 concepts that will be tested: _____,_______ and ____________
MCS or _______ and vegetative state both have ______ and ______

Answer 3

coma, locked in syndrome, conscious wakefulness, minimally conscious state, intact wakefullness, but decreased or absent awareness

Question 4

the part of the brain that allows us to be conscious is ______, if this is damaged, you will have imparied or loss of consciousness

Answer 4

ascending reticular activating system (ARAS)

Question 5

if you have a lesion in the thalamus bilaterally or upper part of the brain stem or bilaterally in the cortex, you can have ___

Answer 5

coma, ascending reticular activating system and their projections are damaged

Question 6

_____has projections to thalamus, hypothalamus, basal forebrain, cortex
_______ intralaminar nuclei – role in maintaining alertness

Answer 6

ARAS, Thalamus

Question 7

Coma is a:
described by:
Usually last
Possible outcomes = brain death, PVS, MCS, or consciousness regained

Answer 7

state of unarousable unresponsiveness usually in this state for a few weeks and then something else, Eyes closed, nonverbal, no purposeful movements
no more than 2-4 weeks - “a transitional state”
brain death, PVS, MCS, or consciousness regained

Question 8

what causes coma?

Answer 8

SITS (structural damage, toxicity, seizure, inadequate cerebral perfusion)
structual brain injuries that affect the reticular activating system; bilateral hemispheric involvement (can start on one side and in trauma can always be impact that pushes everything to one side or compresses the brain stem or cortex)
could also be prolonged seizures, or adegquate blood flow

Question 9

____ does not usually cause a coma unless _____ is involved, while _____ does because of the involvement of the reticular activating symptoms

Answer 9

ischemic stroke, ARAS; basilar artery thrombosis

Question 10

Metabolic/Toxic Mnemonic:HIDEOUS PT (patient)

Answer 10

H – hepatic dysfunction
I – infectious
D – drug effects or withdrawal syndromes
E – electrolyte abnormalities
O – oxygenation and ventilation
U – uremia
S – sugar (hypo or hyperglycemia)
P – pH, acid/base status
T – thyroid

Question 11

If focal problem on exam (one side, etc), think about

Answer 11

structural lesion  need imaging

may have reactivation of old stroke

Question 12

If nonfocal and fluctuating,

Answer 12

concern for seizure vs delirium

Question 13

If nonfocal and not fluctuating,

Answer 13

still could be seizure or structural but more likely to be medication-related, metabolic, or infectious

Question 14

Infectious does not have to be meningitis / encephalitis

Answer 14

Infectious does not have to be meningitis / encephalitis
UTI can cause major AMS in elderly and/or demented
Septic encephalopathy
Neuro patients often look dramatically worse with fever
ESPECIALLY OLDER PEOPLE!

Question 15

one outcome of coma that results in intact arousal but lacking AWARENESS is ______ and is definied by:

Answer 15

vegetative state,

No reproducible, purposeful responses to stimuli

Question 16

Pronator drift:

Answer 16

opposite side weakness of arm (right arm pronator drift means left side umn lesion)

Question 17

vegetative state is being ______ but lacking all ______, while minimally conscious is fully ______ and dimished _______,

Answer 17

fully awake, awareness; awake awareness, not able to make purposeful movements, not able to open eyes

Question 18

confusion suggests: aphasia suggests:

Answer 18

global, focal

Question 19

common cause of vegetative state:

Answer 19

traumatic brain injusry, axonal brain injury, hypoxic brain injury after cardiac arrest

Question 20

pvs is:

Answer 20

persistant vegetative state, can be called this after 1 month

Question 21

pvs is considered permanant after:

Answer 21

3 months due to nontraumatic injury (cardiac arrest), 12 months after traumatic cause

Question 22

minimally conscious pt are:

Answer 22

exhibit some sense of awareness, reproducible behavior, eye contact, turning head to stimuli, hold object, etc, no time intervals

Question 23

localizing in minically conscious pt:

Answer 23

if you are pinched on shoulder, the pt moves to that stimulus

Question 24

Psychogenic:

Answer 24

Psychogenic (catatonia, malingering, conversion)

Question 25

Delirium

Answer 25

Delirium – acute confusional state with impaired attention, very common in hospital – details on next slide

Question 26

Akinetic mutism

Answer 26

Akinetic mutism – bilateral medial frontal lobes
Difficulty with motivation, initiation, and executive function
Awake, able to track, no motor response to stimuli
might not respond if you pinch them, etc

Question 27

Locked-in syndrome

Answer 27

Locked-in syndrome – ventral pons
Loss of bilateral corticospinal and corticobulbar tracts, so patients are quadriplegic with no ability to speak
Caused by pontine infarct, hemorrhage, or trauma
Consciousness intact but minimal ability to interact
Communicate with vertical eye movements or blinks
quadrapaleigic

Question 28

delerium stages; has to have:

Answer 28

Hyperactive, hypoactive, mixed

acute onset, fluctuating course, inattention, then either altered consciousness or disorganized thinking

Question 29

locked in syndrome has

Answer 29

all normal awake, awareness, sleep cycles, brain metabolism

Question 30

an important amino acid to remember is:

Answer 30

thyamine, essential cofactor in metabolism and if pt are deficient, they can not metabolize any of the glucose they are given and it can potentially make them worse acidosis, encephalopathy, etc

Question 31

CN exam: gag and cough are _____, jaw jerk is ____, corneal reflex is ____

Answer 31

9, 10, 5, 5 7?

Question 32

lesion above red nuclei_____ below the red nuclei_____

Answer 32

decorticate (towards DEE CORD), decerebrate

Question 33

on pupil exam, one worth remembering is:

Answer 33

Roving EOMs – intact brainstem, usually bihemispheric injury going slowly back and forth side to side, a sign of cerebellar disfunction

Question 34

breathing patterns to note

Answer 34

cheyne-strokes (dick cheney smoking, like a chain smoker) deep breathes followed by shallow quick breathes, hyperventilation: bihemispheric, midbrain, pontine lesions

Question 35

control center for hr and bp is in:

Answer 35

nucleus solitarius and medullary reticular formation: Inputs from baroreceptors in carotid body (via CN IX) and aortic arch (via CN X)
Projections to parasympathetic and sympathetic preganglionic neurons and to the forebrain

Question 36

interruption in sympathetic projections from medulla to intermediolateral cell column at T1-L2 results in

Answer 36

hypotension seen in cervical and high thoracic spinal cord injuries

Question 37

poor prognosis signs:

Answer 37

lack of pupillary light reflex after 72 hours, presence of myoclonic jerks continuously, extension of diffusion (lights up bright on edges and homogenous) and status eppilepticus

Question 38

2 ways you can die:

Answer 38

cardiac respiratory, comlete loss of function of brain and brain stem

Question 39

Final common pathway =

Answer 39

Final common pathway = cerebral circulatory arrest from intracranial hypertension

Question 40

cardinal findings of coma:

Answer 40

Coma
Absence of brainstem reflexes
Apnea
DNC is a CLINICAL diagnosis
Prerequisites, exam, & apnea test in that order
Absence of clinical brain function when the proximate cause is known and demonstrably irreversible

Question 41

icp has to be higher than map to have:

Answer 41

no brain flow

Question 42

if unable to perform apnea test, you perform an:

Answer 42

ancillary test

Question 43

65 yr old develops slurred speech difficulty swallowing and labored breathing over 30 min. He reaches the ed and needs ventilatory assistance. His arms and legs are flaccid, no voluntary movments in any limbs, able to blink when instructed and appears to have completely intact comprehension of spoken and written language, mri reveals extensive infarction of the ventral pons, the basilary artery is not visible on mra:

Answer 43

locked-in syndrome; consciousness is preserved in the locked-in syndrome but the patient is paralyzed from the eyes down. Usually due to ischemic or hemorrhagic damage to the pons such as that occurring with basilary artery occulsion

Question 44

72 yr old requires bypass surgery to alleviate myocardial ischemia. During surgery he has a massive MI and protracted asystole. Resuscitative measures succed in reestablishing a normal sinus rhythm, but postoperatively the patient remains unconscious after 48 hours. Over the ensuing weeks, the pateint’s level of consciousness improves slightly. He appears awake at times, but does not interact in meaningful ways with visitors. He breathes independently and even swallows food when it is placed in his mouth., but remains mute. With painful stimuli, he exhibits semipurposeful withdrawal of his limbs. His clinical status remains unchanged fr several more months:

Answer 44

vegetative state

Question 45

clinical condition in which autonomic activity is sustained with little evidence of cognitive function. Occurs with extensive damage to the cerebrum (could also occur with drowning or other causes of protracted hypoxia)

Answer 45

vegetative state

Question 46

consciousness is preserved in ______. Usually due to ischemic or hemorrhagic damage to the pons such as that occurring with basilary artery occulsion

Answer 46

locked in syndrome

Question 47

72 yr old admitted to burn unit with 2nd 3rd degree burns covering 35% of body. On day 4 of hospital stay, she starts pulling out i and screaming people are trying to hurt her. Several hours later found to be difficult to arouse and disoriented.

Answer 47

delirium

Question 48

65 yr old hospitalized for acute pneumonia 3 days previously begins screaming for nurse, stating “there are people in the room out to get me,” gets out of bed, begins pulling out iv lines, not oriented to time or place vital signs pulse 126 brpm, rep 32, bp 80/58 temp 102.5:

Answer 48

delirium

Question 49

disturbance of consciousness (decreased arousal) and change in cognition (i.e. sudden paranoia) seen over short period of time and tends to fluctuate over the course of a day. also must be shown that disturbance is caused by direct physiological consequence of a general medical condition

Answer 49

delirium

Question 50

fluctuations in consciousness, disorientation, sleep wake cycle disturbances are all typical of:

Answer 50

delirium

Question 51

76 yr old woman admitted to hospital after found lying on bedroom floor and incoherent. Hypervigilant and disorganized thoughts

Answer 51

delirium

Question 52

most common cause of delirium in the elderly?

Answer 52

multiple medications

Question 53

52 yr old undergoes successful mitral valve replacement, and is sent to intensive care to recover. The next day is irritable, restless, hours later agitated, disoriented, hypervigilant and uncooperative. The agitation alternates with periods of somnolence:

Answer 53

post surgery delirium