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Neurology > Examination Of COmatos Px > Flashcards

Examination Of COmatos Px Flashcards

1
Q

What is the state of full awareness of self and one’s relationship to the environment?

A

Consciousness

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2
Q

What are the 2 components of consciousness?

A

Content & arousal

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3
Q

What are the ways consciousness can be damaged?

A
  1. If there is damage to the cortical networks + diffused -> level of consciousness is affected
  2. Small lesions -> selective or fractional loss of consciousness
  3. Injury to the brain stem or diencephalic pathways -> overall consciousness may be decreased
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4
Q

What is the state of sustained pathologic unsconsiousness?

A

Coma

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5
Q

What happens if there is pain in coma px?

A

Still retain some form of responsiveness in the form of reflex

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6
Q

What are the acute disorders of consciousness?

A

Confusion
Delirium
Obtundation
Stupor
Coma

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7
Q

What is an inappropriate repsponse to the environemnt?

A

Confusion

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8
Q

What is the misperception of sensory stimuli & vivid hallucinations, agitation, and tremulousness?

A

Delirium

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9
Q

What is the mild to moderate reducction in alertness accompanied by lesser interest in the environment??

A

Obtundation

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10
Q

What is the state where px are arousable only by vigorous stimulation?

A

Stupor

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11
Q

What is the main neuroanatomic basis for consciousness?

A

Ascedning reticular activating system

-> network of neurons originating in the tegmentum of the upper pons and midbrain

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12
Q

What are the 2 acetylcholine grps in ARAS?

A

Peduncopontine tegmental nucleus & Lateral dorsal tegmental (LDT) nucleus -> major input

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13
Q

WHat is the pathway of ARAS from LDT & PPT?

A

Inhibition of reticular nucleus -> activation of thalamic relay nucleus -> transmission mode of relaying sensory information

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14
Q

What are the series of direct inputs in ARAS?

A

Monoaminergic
Peptidergic
Cholinergic
Gabaergic inputs

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15
Q

What happens if ther eis unilateral and bilateral cerebral lesion?

A

Unilateral cerebral lesion = does not abolish consciousness

Bilateral cerebral lesion = consciouness is affect

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16
Q

How do you do hx taking in px with decreaed sensorium?

A
  1. Obtain hx from key witnesses
  2. Temporal profile or time over which coma devleops
  3. Onset: acute vs gradual
  4. Symptoms prior to onset of coma
  5. Recent complaints
  6. Previous medical illnesses
  7. Previous psychiatric hx
  8. Access to frugs and other medications
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17
Q

If u observe rapid progression of hemiparesis, hemisensory deficit or aphasia to coma from mins to hrs, what do u suspect is the cause?

A

Intracerebral hemorrhage

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18
Q

What do u suspect if px presents with delirium, agitation, changes in behavior without lateralizing signs & symptoms, associated w/ fever?

A

Infection (meningitis or encephalitis(

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19
Q

What is indicated if there is acute confusional state prior to the coma?

A

Metabolic derangement

20
Q

what are done in Gen PE in px with decreased sensorium?

A
  • Vital signs
  • Evidence of trauma
  • evidence of acute/chronic systemic illness
  • evidence of durg ingestions
  • nuchal rigiditiy =assume that cervical trauma has been excluded then exam for potential CNS infection
21
Q

what are indications of extreme hypertension?

A
  • posterior reversible encephalopathy syndrome
  • HTN encephalopathy
  • HTN intracerebral hemorrhage
22
Q

what are the causes of Hypotension in px with DEC sensorium?

A

sepsis
hypovolemia
cardiac failure

23
Q

what are the causes of Hyperthermia in px with DEC sensorium?

A

infection
antiocholinergic intoxication

24
Q

what are the causes of hypothermia in px with DEC sensorium?

A

hypothyroidism
sepsis
alcohol intoxication

25
Q

what are the causes of hypothermia in px with DEC sensorium?

A

hypothyroidism
sepsis
alcohol intoxication

26
Q

what are the possible causes of Ecchymosis, Petechial-purpuric rash, Icterus & cherry-red skin?

A

Ecchymosis = trauma, corticosteroid use, abnormal coag from liver dis or Anticoagulants

Petechial purpuric rash = meningococcemia, gonococcemia, staphylococcemia, etc

Icterus = hepatic dysfunction or hemolytic anemia

Cherry-red skin = CO poisoning

27
Q

How do you assess the levels of consciousness?

A
  1. verbal stimulation or sound stimulation
  2. tactile stimulation
  3. painful stimulation = compression of nail bed, supraorbital ridge or temporomandibular joint
28
Q

what are the GCS interpretation?

A

> 13 = mild brain injury
9-12 = Moderate brain injury
<8 = severe brain injury

29
Q

in what cases do you see unilateral dilated pupil in comatose px?

A

posterior communicating artery aneurysm or temporal lobe herniation

30
Q

what reflex is an example of Spinobulbospinal response where pain stimulus arises from the CN V or spinal dorsal horn?

A

Ciliospinal reflex = indicates integrity of these circuits form lower brainstem to spinal cord

31
Q

what are the Oculocephalic response & Vestibulo-ocular response?

A

Oculocephalic response
= integrity of midbrain & pons
= done if suspected injury is at the CERVICAL SPINE

Vestibulo-ocular response
= check for brainstem dysfunction

32
Q

what are the response of intact & damage brainstem when indicating Oculocephalic response?

A

intact brainstem = conjugate movement of the eyes in the direction opposite to the head movement

dysfunctional/damaged brainstem = absent or asymmetric response

33
Q

how do u elicit the corneal reflex in comatose px?

A

vigorous stimulation by not touching the cornea with any material

34
Q

where does the network of neurons responsible for respiratory rhythm located?

A

Ventrolateral medulla inclusing pre-Botzinger complex

35
Q

what is the pattern of periodic breahting with phases of hyperpnea alteration regularly with apnea?

A

Cheyne-stroke respiration
- seen in forebrain or diencephalic function or metabolic encephalopathies

36
Q

In what cases do u see posthyperventilation apnea?

A

Diffuse metabolic impairment of forebrain or bilateral structure damage to the frontal lobes

  • respiration stops after deep breathing has lowered CO2 content in the blood
37
Q

in what cases do u see hyperventilation in comatose px?

A

hepatic coma
sepsis
conditions with chemical stimuli cause hyperpnea
due to metabolic acidosis (diabetic keotacidosis)

38
Q

what is indicated if there is apneustic breathing?

A

Apneustic breathing = respiratory pause @ full inspiration

Cause:
- injury to pontine respiratory nuclei
- setting of pontine infarction due to basilar a occlusion
- metabolic encephalopathy (hypoglycemia, anoxia or CNS infection)
- transtentorial herniation as brainstem dysfunction advances

39
Q

what is the cause of ataxic breathing in comatose px?

A

Ataxic breathing = irregular gasping respiratory

Cause
- damage to respiratory rhythm generator at pre-Botzinger level of upper medulla
- bialteral rostral medullary lesions

40
Q

What are the causes of sleep apnea and Ondine’s curse?

A

Obstructive sleep apnea = cross-section of upper airway is anatomically narrow

Ondine’s curse = central hypoventilation syndrome

41
Q

how do u detect hemiplegia in unconscious px?

A
  1. Inspection = look for unilateral asymmetry of movement, posture, muscle tone, unilateral flaccidity
  2. Flaccidity of the cheek = sucks in inspiration & puff out with expiration
  3. Eyelid release test = gently pull both eyelids up with 2 thumbs then release them simultaneously
  4. Limb drop test =wrist, arm, leg dropping
42
Q

what is the result of hemiplegia in unconscious px in eyelid release test?

A

eyelid of hemiplegic side glides down slowly, whereas opposite lid closes rapidly

43
Q

what are the best motor response to sensory stimulation?

A
  1. decorticate posturing = rubrospinal tract
  2. decerebrate posturing = vestibulospinal tract
44
Q

what are the diff motor tests done in unconscious px?

A

motor reflex = cutaneous, prefrontal cutaneous, muscle stretch
rostro-caudal deterioration
central syndrome

45
Q

what is a positive apnea test?

A

no respiratory response to a PaCO2 >60mmHg

46
Q

what are the prerequisites of apnea test?

A
  1. core temperature >36C
  2. SBP >100mmHg
  3. Eucapnia (PaCO2 35-45mmHg)
  4. Absence of hypoxia
  5. Euvolemic status
47
Q

what are the factors that may mimic brain death?

A

locked-in syndrome
fulminant Guillan-Barre syndrome
Severe hypothermia
Post-cardiac arrest syndrome
Massive baclofen/anticholinergic overdose
Severe overdose of CNS depressants, valproic acid, tricyclic antidpressants

Neurology (8 decks)

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