Neurology: Stupor and Coma

Question 0

What are some structural causes of comas?

Answer 0

• trauma
• hemorrhage (usually damaged cerebral hemispheres)
• infarct (mainly in brainstem: RAS)
• tumor or abscess

Question 1

What two things must be intact to remain conscious?

Answer 1

1. Cerebral Hemispheres
2. Reticular Activating System

if either is lost the patient goes into a coma

Question 2

What is the most common diffuse cause of comas?

Answer 2

Hypoxia in the brain.

-can result from drowning, MI, stroke

Question 3

What are the top two causes of coma in general?

Answer 3

Alcoholism and Trauma

Question 4

What are the 3 levels for checking alertness?

Answer 4

1. Verbal
2. Tactile
3. Noxious

Question 5

If a patient is unconsious, what can decorticate and decerebrate postures tell the physician?

Answer 5

Decorticate: means lesion is in the thalamus and hemispheres
Decerebrate: means the lesion is in the midbrain

Question 6

Assessing the respiratory pattern of a comatose patient is important. Describe Cheyne-Stokes and what it means?

Answer 6

CS: alternating loud and quiet breathing

Indicates heart failure or a lesion in the thalamus or higher

Question 7

Assessing the respiratory pattern of a comatose patient is important. Describe central neurogenic hyperventilation and what it indicates.

Answer 7

Shallow rapid breathing. Indicates a midbrain lesion.

Question 8

Assessing the respiratory pattern of a comatose patient is important. Describe apneustic breathing and what it means.

Answer 8

Patients will have slow breathing, holding breaths in for extended periods of time and then holding exhalation for an extended period of time. Indicates pontine lesion.

Question 9

Assessing the respiratory pattern of a comatose patient is important. What does apnea or gasping indicate?

Answer 9

Medullary lesion, location of the primary respiratory center

Question 10

Will a patient show nystagmus in a coma?

Answer 10

No, the cerebral hemispheres need to be intact for nystagmus to occur.

Question 11

What 4 signs would indicate a lesion at the thalamus or higher?

Answer 11

1. Cheyne-Stokes breathing
2. Small Reactive pupils
3. Decorticate posturing
4. Brainstem reflexes intact

Question 12

4 signs that the lesion is at the midbrain in a comatose patient.

Answer 12

1. Central neurogenic hyperventilation
2. Mid-position fixed pupils
3. Decerebrate posturing
4. EOM impaired (depending on location of lesion in midbrain)

Question 13

5 things that occur in a coma caused by a pontine injury.

Answer 13

1. Apneustic respiration
2. Mitotic Pupils (pin point)
3. Absent EOM
4. Absent corneal reflex
5. Flaccidity

Question 14

4 things that occur in a coma caused by a medullary lesion.

Answer 14

1. Gasping or apnea
2. Flaccidity
3. Absent gag reflex
4. BP or HR irregularities

Question 15

What is the first thing to remember when treating a comatose patient that presents to the ER?

Answer 15

Secure an airway.

Question 16

Describe the presentation of an uncal herniation.

Answer 16

Blown Pupil, ptosis, eye deviation down and out.
-uncus herniates into tentorial notch (area between cerebral peduncles) compressing CN III as it exits the midbrain.

Patients will have impaired consciousness distinguishing the eye problems from aneurysm or diabetic infarct.

Patients may also have bouncy reflexes usually contralateral to the side of the herniation. (Herniation may be big enough to manifest bilateral hyperreflexia)

Question 17

What is necessary to confirm and diagnose brain death?

Answer 17

• Absent cerebral and brainstem responses
• Apnea
• Absent cerebral blood flow
• A known diagnosis
• Absence of drug intoxication and hypothermia (both of which can mimic brain death but resolve when the problem is corrected)

(not all of these are needed)

Question 18

In the Glasgow Coma Scale, describe the scale of 1-4 for the eyes.

Answer 18

1. Never open
2. open with pain
3. open to verbal stimuli
4. open spontaneously

Question 19

In the Glasgow Coma Scale, describe the scale of 1-5 in verbal response.

Answer 19

1. No response
2. incomprehensible sounds
3. inappropriate words
4. disoriented and coverses
5. oriented

Question 20

In the Glasgow Coma Scale, describe the scale of 1-6 for motor response.

Answer 20

1. none
2. decerebrate
3. decorticate
4. flexion withdrawal
5. localizes pain
6. obeys