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Ahmed Neuro 2 Depression > Lecture 12: Stupor and Coma > Flashcards

Lecture 12: Stupor and Coma Flashcards

1
Q

Consciousness depends on arousal of the cerebral cortex by the ____________

A

Brainstem Ascending Reticular Activating System (ARAS)

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2
Q

Impaired consciousness means involvement of what 3 things?

A
  1. Diffuse or bilateral impairment of both cerebral hemispheres, or
  2. Failure of brainstem ARAS, or
  3. BOTH
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3
Q

Which state of altered consciousness is represented by disorientation, stimuli misinterpretation, and hallucinations (visual)?

A

Delirium

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4
Q

Which state of altered consciousness is represented by arousal only to noxious stimuli and not enviornmental, only rudimentary awareness (i.e., purposeful motor response)?

A

Stupor

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5
Q

During a general medical exam of the skin of a patient with impaired consciousness what should be considered with dry skin?

A
  • Hypothyroid
  • Drugs (anticholinergics, TCA’s)
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6
Q

During a general medical exam of the skin of a patient with impaired consciousness what should be considered with acne?

A

Long-term antiepileptic use

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7
Q

Large, pressure producing supratentorial mass lesions can cause coma how?

A
  • Dysfunction in the upper ARAS
  • Downward herniation of the brain to compress the ARAS
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8
Q

What are the essential elements of the neurological examination for a patient with stupor?

A
  • Pupillary responses
  • Corneal reflex
  • Extaocular movements
  • Cough/gag reflex
  • Motor responses
  • Respiratory pattern

*Start at highest CN and work your way down

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9
Q

Why do absent or unequal pupillary responses imply a brainstem lesion?

A

Nuclei/tracts controlling pupils are anatomically adjacent to ARAS

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10
Q

What are the 3 P’s associated with pinpoint pupils?

A

1) Pontine lesion
2) oPiates
3) Pilocarpine

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11
Q

Rule of thumb for lesion location when pupils are enlarged on one side?

A

Parasympathetic division (usually CN III)

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12
Q

Rule of thumb for lesion location when pupils are enlarged bilaterally?

A

Bilateral CN III lesion, post-ictal, or intoxications

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13
Q

Rule of thumb for lesion location when pupils are constricted?

A

Sympathetic division (hypothalamus, carotid)

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14
Q

Frontal gaze centers deviate eyes where?

Pontine gaze centers deviate eyes where?

A
  • Frontal gaze centers deviate eyes to opposite side (i.e., if right area is dysfunctional, there is no drive to the left, so eyes will be looking right)
  • Pontine gaze centers deviate eyes to same side
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15
Q

What does conjugate vs. dysconjugate gaze imply about the brainstem?

A
  • Conjugate implies brainstem intact
  • Dysconjugate implies brainstem lesion
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16
Q

What is the location of the lesion if the eyes have a ping-pong nystagmus?

A

Bihemispheric, midbrain

17
Q

Convergence nystagmus or Retractory nystagmus indicates a lesions where?

A

Mesencephalon

18
Q

Bobbing nystagmus (rapid down, slow up) indicates a lesion where?

A

Pons

19
Q

Which level of the pons is assessed with the Oculocephalic manuever (Doll’s Eyes) vs. Caloric (oculovestibular) reflex test?

A
  • Oculocephalic = mid pons; assess CN III, IV, and VI
  • Caloric = lower pons
20
Q

What is Decorticate vs. Decerebrate posturing and where is the lesion for each?

A
  • Decorticate = arms flexed, legs extended (hemispheric)
  • DEcrebrate = all extremities Extended (brainstem)
21
Q

What are Cheynes-Stokes respirations?

Seen with what disorders?

A
  • Hyperpnia regularly alternating w/ apnea (bilateral hemispheres or diencephalon)
  • Many disorders ranging from metabolic to structural
22
Q

The initial signs of a supratentorial mass lesion are usually (global or focal)?

How do the signs progress?

Motor signs are often?

A
  • Initial signs usually focal
  • Progression of signs is rostral to caudal (i.e., herniation pushing down)
  • Motor signs are often asymmetric
23
Q

What is central transtentorial herniation and the signs/symptoms?

A
  • Herniation into foramen magnum
  • Leads to early coma, small pupils, normal EOM’s, posturing and later bilateral fixed pupils
  • Respiratory arrest and death
24
Q

What is commonly seen preceding brainstem dysfunction (4 D’s) due to a subtentorial mass lesion?

A
  1. Dysequilibrium
  2. Dysarthria
  3. Dysphagia
  4. Diplopia

*Vertigo

25
Q

What are the respiratory patterns of someone with a subtentorial mass lesion?

A

Bizarre respiratory patterns common

26
Q

What is the characteristic signs of someone with diffuse/metabolic injury of the nervous system (i.e., motor signs, consciousness, breathing, and presentation)?

A
  • Confusion and stupor commonly precede motor signs
  • Motor signs usually symmetrical
  • Pupillary rxns usually preserved
  • Asterixis, myoclonus, tremor, seizures common
  • Acid-base imbalance with hyper or hypoventilation
  • Fluctuating level of consciousness
27
Q

What must be known when making the call of brain death?

A

Cause of the coma should be known, it MUST be adequate to explain the clinical picture, and it MUST be irreversible

28
Q

What must be ruled out before making the call that someone is brain dead?

A
  • Sedative intoxication
  • Hypothermia (<90F)
  • Neuromuscular blockage
  • Shock

*All can mimic brain death*

29
Q

What defines unresponsivness in someone who is truly brain dead?

Absence of?

A
  • Unresponsive to ALL sensory input, including pain and speech
  • Absent brainstem reflexes
30
Q

Which test can be done to clinically document someone as being brain dead?

A
  • Apnea test
  • Disconnect ventilator –> Catheter w/ 100% O2 and observe chest wall and abdomen for movement
  • No respiratory movements for 8 mins (PCO2 >60mmHg
31
Q

What are the criteria for persistence of brain death?

A
  • 6 hours w/ confirmatory (flat) EEG: performed to tech. standards of AEES
  • 12 hours w/o a confirmatory isoelectric EEG
  • 24 hours for anoxic brain injury w/o confirmatory isoelectric EEG
32
Q

What are the 3 intial steps of managing a comatose patient?

A

1) A: insure patent airways
2) B: insure breathing and adequate oxygenation
3) C: insure adequate circulation and control any active bleeding

*Stabilize neck, get C-spine films if trauma suspected

33
Q

What are specific interventions that can be done to reduce ICP?

A
  • Elevate head of bed
  • Intubate and hyperventilate to PCO2 of 20 mmHg
  • Use mannitol for ischemic lesions
  • Use decardron for tumor, abscess, and perhaps cerebral hemorrhage
34
Q

What is the characteristic sign of Hepatic dysfunction causing stupor and coma?

A
  • Asterixis!
  • Pt extends arms and wrists, the wrists will twitch!

Ahmed Neuro 2 Depression (16 decks)

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