Rockroth: Stupor and Coma Flashcards
What is coma?
complete lack of consciousness;
no awareness of surroundings
What makes stupor different from coma?
if you have SOME conscious awareness of your surroundings, you are in stupor
What do you need to get decreased level of consciousness, either coma or stupor?
you either turn off all bulbs on the tree (all neurons) or you cut the cord
If you have focal neurologic deficits greater than loss of consciousness, what should you think of?
intracerebral problem
If you have greater loss of consciousness than focal neurologic deficit, what should you think of?
**stuporous but normal eyes, eye movements, etc
extracerebral problem
Which is worse, decerebrate or decorticate posture?
decerebrate
What is happening in this case?
On exam in the ED his BP is 230/122. He is awake, alert and appropriately conversant. His speech is slurred (dysarthric) but intelligible. He follows 3-step commands accurately. He cannot sit or stand without falling towards the left. His strength is normal to direct testing.
In the ICU one hour later he is no longer responsive to verbal stimuli.
He exhibits bilateral decerebrate posturing with application of nail bed pressure to either hand.
His pupils are equal/4mm and unresponsive to light.
intracerebellar hemorrhage
**may expand in size over the first hrs leading to clinical deterioration
**may cause cerebellar tonsils to herniate thru foramen magnum
When will you get focal signs with subarachnoid hemorrhage?
only if the bleeding extends into the brain parenchyma or if the patient suffers vasospasm or ischemic stroke
SAH causes increased ICP, so what might you see?
early papilledema
Cushing’s sign
How to begin examining the stuporous/comatose patient when you enter the room?
Observe!!!
Spontaneous movement? Reflex or volitional?
Breathing pattern? (Cheyne-Strokes breathing)
What things can you observe about a patient’s breathing?
Cheyne-strokes breathing
**Cheyne-Stokes breathing is one deep breath, then subsequent breaths decreases until the PCO2 builds up – this type of breathing is controlled by the PCO2 – this tells you the brainstem is intact!
Is the patient intubated or ventilated? Are they overbreathing the ventilator?
**if they are overbreathing, they have some awareness
How do you actually examine the pt that is comatose?
look at response to stimuli
“Mr. Jones, open your eyes!”
Lift their eyelids, look at their pupils, look at the fundus, look at eye movements
the absence of a pupillary light response in a comatose patient typically connotes a (blank)% chance of meaningful neurologic recovery
ZERO
How is the diagnosis of brain death made?
made via history and bedside exam
What components should you look at on the bedside exam to confirm or refute brain death?
loss of consciousness?
pupils, corneal response, doll’s eyes, VOR?
apnea test?
