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Clin Med B 2 > (Enochs + some)Lecture 3: Disorders of Consciousness > Flashcards

(Enochs + some)Lecture 3: Disorders of Consciousness Flashcards

1
Q

Define consciousness

A

State of awareness to environment and self with a responsiveness to stimuli

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2
Q

What is the reticular system

A

set of neurons in the brain stem consisting of the ascending reticular activating system and the descending reticulospinal tracts.

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3
Q

What system controls consciousness and where is it located?

A
  • Ascending reticular activating system
  • This originates in the upper pons and midbrain
  • Extending to the brainstem and cortex

Controls the level of alertness

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4
Q

What is the function of the descending reticulospinal tract?

A
  • does NOT affect consiousness
  • travels downward into the spinal cord and modulates spinal reflex activity
  • damage leads to lost/diminished reflexes
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5
Q

What mainly composes the cerebral cortex? what occurs here

A
  • mainly composed of Grey matter
  • controls the content of conciousness such as:
  • self awareness, language, reasoning, spatial relationship, integration and emotions
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6
Q

What is consciousness

A
  • awake/alert and responsive to stimuli.
  • fast neuronal signals passed between areas of the ARAS
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7
Q

What is unconsciousness?

A
  • Unawareness and unresponsiveness to stimuli resulting from damage to the ARAS or cerebrum.
  • diminished transmission signals from ARAS and cerebrum

Sleep does not qualify since you still are responsive.

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8
Q

What are the 5 LOCs? (image)

A

ALOSC

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9
Q

evaluation of the unconscious patient (pic)

I just think glancing at this is a good idea!

A
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10
Q

What is in the primary survery?

A
  • Circulation (carotid)
  • Airway
  • Breathing

no pulse = start CPR
spontaneous regular respirations = monitor
no respiration/ineffective respirations = provide ventilation

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11
Q

What is considered severe MAP in regards to an unconscious patient?

A

treat SEVERE HTN= MAP > 130
treat hypotension = MAP<70

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12
Q

How do you calculate MAP?

A

(SBP + 2(DBP))/3

1 2 3

1 systolic
2 diastolics
3 divisions

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13
Q

what labs should you obtain initially on a unconscious patient

A

CBC
Glucose
Electrolytes
BUN/Cr
LFTs
PT
ABG
Drug screen
ETOH
Ammonia

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14
Q

If we have an unconscious patient, what 3 things can we administer IV?

A
  • Dextrose ONLY for hypoglycemic patients.
  • Thiamine (with or before glucose) for Wernicke encephalopathy
  • Naloxone (Opiate OD)

All of these are generally not harmful.

Thiamine helps glucose uptake, and it has no harmful effects to someone who is not thiamine deficient.

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15
Q

What conditions would cause immediate onset unconsciousness?

A
  • SAH
  • Seizure
  • Cardiac arrhythmia
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16
Q

what would cause gradual onset unconsciousness

A
  • infectious
  • space occupying lesion
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17
Q

what would cause fluctuating unconscioussness

A
  • recurring seizures
  • ssubdural hematoma
  • metabolic disorders
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18
Q
A
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19
Q

What treatments are used for ingestion of BZD, opiates or other ingestion

A
  • flumazenil for CONFIRMED BZD OD
  • narcan for opiates
  • gastric lavage/activated charcoal if unknown
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20
Q

What empiric ABX could be used for an unconscious patient d/t a possible infection?

A
  • Rocephin + Vanco
  • Acyclovir
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21
Q

For increased ICP, what meds can we use?

A
  • Glucocorticoids
  • Mannitol
  • Position head of bed to 30deg
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22
Q

For non-convulsive seizures, what are some meds we can use?

A
  • Lorazepam
  • Phenytoin or equivalent
23
Q

What does a focal neurologic abnormality suggest for underlying etiology on an unconscious patient?

A

Structural lesion

24
Q

What skin finding can suggest IVDU?

A

Track marks

25
Q

What does pupil reactivity tell you about potential lesion location?

A
  • A non-reactive pupil suggests upper brainstem lesion.
  • Reactive suggests widespread structural lesions or metabolic suppression of the cerebral hemispheres
26
Q

What is doll’s eyes/oculocephalic reflex?

A

An abnormal reflex means the eyes will remain midline as they are moved. (The eyes will NOT stay fixed)

DO NOT USE IF C-SPINE TRAUMA IS SUSPECTED.

27
Q

What is the alternative to testing the oculocephalic reflex? When do we use it?

A
  • Cold caloric stimuli
  • Used when C-spine is NOT cleared.
  • Cold saline into ear should cause ipsilateral eye movement, but nystagmus will go back towards opposite ear. (Normal test)

Tests the oculovestibular reflex.

Intact brainstem will allow the ipsilateral movement.
However, cortical damage will delay the return.

Abnormal Response = no turning towards the ear being irrigated.

28
Q

what is the catch for using the oculovestibular reflex

A

must have intact TM and clear canals

29
Q

How do you test the gag reflex (9&10) in an intubated patient?

A

Deep suction should cause a cough reflex.

30
Q

Describe Cheyne-stokes respirations.

A
  • Progressive Hyperpnea followed by brief apnea
  • Indicative of lower medullary dysfunction
31
Q

Describe apneustic breathing.

A
  • Prolonged inspiratory phase or end-inspiratory pause
  • Higher medullary dysfunction
32
Q

What test can be used to assess muscle tone in an unconscious patient?

A
  • Arm drop test.
  • A truly unconscious patient will hit themselves in the face if the hand is dropped on top.
  • A malingering patient will avoid hitting themselves even if they are “unconscious”
33
Q

What are the possible responses to central painful stimulation?

sternal rub, supraoc pressure, jaw angle pressure, med trapezius pinch

A
  • localized - UE movement toward the painful stimuli - indicates lesser depth of coma
  • flexor posturing (decorticate)
  • extensor posturing (decerebrate)
  • no response
34
Q

Describe decerebrate posturing. what damage is indicated here?

A

Decerebrate: extensor posturing

Cerebrate has a lot of Es, and so does extensor.

Considered the more severe of the two posturings.
Damage to Lower midbrain and upper pons.

35
Q

Describe decorticate posturing. what damage is indicated here?

A

Flexor posturing

Decorticate is pulling to the CORe

Damage to upper midbrain

36
Q

What are the 3 categories of the GCS?

A
  • Eye opening Response
  • Verbal Response
  • Motor Response

3-15

Minor: 13-15
Mod: 9-12
Severe: 3-8

37
Q

When is a CT head w/o con considered an emergent scan to order?

A
  • Focal neurologic deficits
  • Papilledema
  • Fever

looks for hemorrhage, neoplasm, abscesses, signs of trauma, causes of increased ICP

38
Q

When is a LP considered emergent post CT scan? what is the CI for this?

A
  • Fever
  • Elevated WBCs
  • Meningismus

CI in cerebral edema or increased ICP.

more sensitive for subarachnoid hemorrhage than CT if >6 hours of onset

39
Q

What etiology is EEG primarily used to look for?

A

Nonconvulsive seizures resulting in diminished consciousness.

40
Q

What do evoked potentials measure?

A
  • utilizes visual, auditory, and somatosensory (touch) stimulation to assess electrical signals to the brain
  • Results reveal how long it takes from an impulse to get from one location to the other.
41
Q

What is the most sensitive imaging modality of the brain?

A

MRI Brain

though 2nd-line bc it takes a long time.

42
Q

What are the 3 pathophysiological processes that can result in unconsciousness?

A
  1. Lesions that damage the RAS in the upper midbrain or its projections
  2. Destruction of large portions of both cerebral hemispheres
  3. Suppression of reticulocerebral function. (can be d/t toxins, anoxia, uremia, hypo/hyperglycemia, hepatic failure.)
43
Q

What is a coma?

A

Sleep-like state with No purposeful response and patient cannot be aroused for >1 hour

  • Eyes are closed and do not open spontaneously
  • Lacking verbal communication
  • No purposeful movement of the face or limbs
  • Verbal stimulation produces no response
  • Painful stimulation may produce no response or nonpurposeful reflex movements mediated through spinal cord or brainstem pathways
44
Q

What is psychogenic unresponsiveness?

A
  • Prolonged, motionless, dissociative attack
  • Absent or reduced response to external stimuli

Neuro disorders usually. Dx of exclusion!!!!

Underlying etiologies: schizo (catatonia), conversion disorder, somatoform disorder, or malingering

45
Q

How is psychogenic unresponsiveness confirmed?

A

Cold caloric testing with a normal response.

46
Q

What is a persistent vegetative state?

A
  • State of wakefulness but not awareness lasting > 1 month
  • Intact brainstem and autonomic damage
  • Severe, bilateral hemispheric damage.
47
Q

When is prognosis poor for a persisten vegetative state?

A
  • Medical cause with state > 3 months
  • TBI induced > 12 months
48
Q

What is locked-in syndrome?

A
  • Awake, fully alert, fully aware
  • Mute, quadriplegic
  • Decerebrate posturing or flexor spasms can be seen.
  • Voluntary eye movements.
49
Q

What is the underlying pathophysiology that leads to locked-in syndrome?

A
  • Acute, destructive lesions involving ventral pons but sparing the tegmentum.
  • Often due to embolic occlusion of basilar artery
50
Q

What is the description for brain death?

A
  • Irreversible cessation of all brain function.
  • Complete unresponsiveness to speech and painful stimuli
  • Absent brainstem reflexes
  • Etiology must be known and prognosis irreversible.
51
Q

What is the diagnostic criteria for brain death?

A
  • 6 hrs with isoelectric/flat EEG
  • 12 hrs w/o EEG
  • 24 hrs for anoxic brain injury w/o EEG
52
Q

How do we manage coma long-term?

A
  • Manage underlying etiology
  • Maintain airway/adequate respirations
53
Q

GCS Mnemonic

A
  • E: eyes shut (1)
  • Y: Y shaped pain (2)
  • E: ear piercing (3)
  • S: spontaneous (4)
  • V: Voiceless (1)
  • O: Obscure, incomprehensible (2)
  • I: Inappropriate but comprehensible (3)
  • C: Confused but able to answer (4)
  • E: Elegant (5)
  • O: Obey Verbal (6)
  • L: Localizes to pain (5)
  • D: draws away from pain (4)
  • B: bends on pain (3)
  • E: extends on pain (2)
  • N: No motor response (1)

EYES VOICE OLDBEN

Just remember that OLDBEN starts at 6.

Clin Med B 2 (44 decks)

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