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Neuro > Lecture 3: Disorders of Consciousness > Flashcards

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 system controls consciousness and where is it located?

A
  • Ascending reticular activating system (ARAS)
  • Originates in the upper pons and midbrain
  • Extending to the brainstem and cortex

Controls the level of alertness

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3
Q

What mainly composes the cerebral cortex?

A

Grey matter

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4
Q

What causes unconsciousness?

A

Damage to the (ascending reticular activating system) ARAS or cerebrum.

Slow impulses.

Sleep does not qualify since you still are responsive.

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5
Q

What are the 5 LOCs? (image)

A

ALOSC

Sound, touch, pain

Alphabetical up to coma

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6
Q

What is in the primary survey of a patient?

A
  • Circulation (carotid)
  • Airway
  • Breathing

Easier to just remember ABCs

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7
Q

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

A

MAP > 130

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8
Q

How do you calculate MAP?

A

(SBP + 2(DBP))/3

1 2 3

1 systolic
2 diastolics
3 divisions

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9
Q

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

A
  • Dextrose 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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10
Q

What conditions would cause immediate onset unconsciousness?

A
  • SAH
  • Seizure
  • Cardiac arrhythmia
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11
Q

When can flumazenil be used?

A

CONFIRMED BZD OD

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12
Q

What empiric ABX could be used for an unconscious patient?

A
  • Rocephin + Vanco
  • Acyclovir
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13
Q

For increased ICP, what meds can we use?

A
  • Glucocorticoids
  • Mannitol
  • Position head of bed to 30deg
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14
Q

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

A
  • Lorazepam
  • Phenytoin or equivalent
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15
Q

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

A

Structural lesion

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16
Q

What skin finding can suggest IVDU?

A

Track marks

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17
Q

What does pupil reactivity tell you about potential lesion location?

A

A non-reactive pupil suggests upper brainstem lesion.

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18
Q

What are 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.

Involves head turning

19
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.

20
Q

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

A

Deep suction should cause a cough.

21
Q

Describe Cheyne-stokes respirations.

A
  • Progressive Hyperpnea followed by brief apnea
  • Indicative of lower medullary dysfunction
22
Q

Describe apneustic breathing.

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

A = apex = higher medullary

23
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”
24
Q

Describe decerebrate posturing.

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.

25
Q

Describe decorticate posturing.

A

Flexor posturing

Decorticate is pulling to the CORe

Damage to upper midbrain

26
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

27
Q

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

A
  • Focal neurologic deficits
  • Papilledema
  • Fever
28
Q

When is a LP considered emergent post CT scan?

A
  • Fever
  • Elevated WBCs
  • Meningismus

CI in cerebral edema or increased ICP.

29
Q

What etiology is EEG primarily used to look for?

A

Nonconvulsive seizures resulting in diminished consciousness.

30
Q

What do evoked potentials measure?

A

How long it takes from an impulse to get from one location to the other.

31
Q

What is the most sensitive imaging modality of the brain?

A

MRI Brain

2nd-line bc it takes a long time.

32
Q

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

A
  1. Lesions that damage the RAS in the midbrain or its projections
  2. Destruction of large portions of both cerebral hemispheres
  3. Suppression of reticulocerebral function.
33
Q

What is a coma?

A

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

34
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

35
Q

How is psychogenic unresponsiveness confirmed?

A

Cold caloric testing with a normal response.

36
Q

What is a persistent vegetative state?

A
  • State of wakefulness but not awareness lasting > 1 month
  • Intact brainstem and autonomic function
  • Severe, bilateral hemispheric damage.
37
Q

When is prognosis poor for a persistent vegetative state?

A
  • Medically caused with state > 3 months
  • TBI induced > 12 months
38
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.

Brain awake but nothing can move

39
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

there is a house episode on this if you’re interested

40
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.
41
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
42
Q

How do we manage coma long-term?

A
  • Manage underlying etiology
  • Maintain airway/adequate respirations
43
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.

Neuro (17 decks)

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