Delirium & Coma

Question 1

Ascending Reticular Activating System (RAS):

Answer 1

Begins: Reticular formation of paramedian tegmental region of pons and midbrain.
Ascends to: Bilateral Thalami
Ascends to: Bilateral Cortex

Question 2

Electrolyte disturbances that cause delirium and lethargy:

Answer 2

Hypocalcemia: delirium.
Hypercalcemia: lethargy.
Hyponatremia.

Question 3

Coma is almost always caused by structural lesions. What are exceptions to this.

Answer 3

Meds.
Status epilepticus.
Anesthetics agents.
Brain hypoxia.

Question 4

Comatose =

Answer 4

No response too any stimulus

Question 5

Stuporous =

Answer 5

Grimace only. Cannot arouse to verbal or negative stimulus.

Question 6

Obtunded =

Answer 6

Sleepy, Awakened with verbal/negative stimulus.

Question 7

Somnolent =

Answer 7

Sleepy, arouses with stimulus, able to maintain awake state.

Question 8

Cushing triad = __. When is it seen?

Answer 8

HTN, Bradycardia, Respiratory change.

Seen in acute increased ICP and imminent cerebral herniation.

Question 9

Roving eye movement?

Answer 9

Bilateral Hemisphere Injury

Question 10

Gaze deviation?

Answer 10

Unilateral injury to gaze holding centers

Question 11

Ocular bobbing=? Caused by?

Answer 11

Conjugate gaze with slow drift down and rapid jerk up.

Brainstem dysfunction

Question 12

Unilateral dilated and unreactive eye caused by?

Answer 12

Compression of CNIII in subarachnoid space for aneurysm - until proven otherwise

Question 13

Bilateral dilated and unreactive eyes caused by?

Answer 13

Compression of CNIII in subarachnoid space from herniation

Question 14

Bilateral pinpoint pupils

Answer 14

Either pontine damage or opiates

Question 15

Corneal exam assesses?

Answer 15

Ipsilateral CNV1, Bilateral CNVII

Question 16

Threat response assesses?

Answer 16

visual fields

Question 17

Cheyne-Stokes

Answer 17

An abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in apnea.
Damage in Deep Hemisphere or Diencephalon.

Question 18

Rythmic Hyperventilation caused by?

Answer 18

Pulm/Metabolic problems.

Central Neurogenic - Midbrain, Upper pons.

Question 19

Apneusis

Answer 19

Sustained, gasping inhalation followed by short, inefficient exhalation, which can continue to the point of asphyxia.
Damage to Dorsomedial Medulla.

Question 20

Cluster breathing

Answer 20

A breathing pattern in which a closely grouped series of respirations is followed by apnea.
Damage to Low Pons, High Medulla.

Question 21

Ataxic breathing

Answer 21

Complete irregularity of breathing, with irregular pauses and increasing periods of apnea.
Damage to Dorsomedial Medulla

Question 22

If elevated ICP do:

Answer 22

1. Elevate head of the bed
2. Hyperventilate with pH goal 7.5. Arterial constriction and reduced blood volume.
3. Hyperosmotic agent: Mannitol or Hypertonic Saline (reduce brain volume)
4. Neuroanesthetics: propofol/BARBs. Reduce brain metabolism.
5. External Ventricular Drainage (EVD). Reduce CSF. Do NOT do LP!-risk herniating
6. Craniectomy