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NS2 Test 3 > Stupor and Coma > Flashcards

Stupor and Coma Flashcards

1
Q

What is consciousness? Requirements?

A
  • total awarness of self and environment
  • arousal (alertness)
  • awareness (sum of cognitive mental functions)
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2
Q

consciousness depends on?

A
  • arousal of cerebral cortex by brainstem ascending reticular activating system (RAS)
  • input from sensory
  • projects to hypothalamus, thalamus, cortex
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3
Q

impaired consciousness means?

A
  • diffuse or b/l impairement of both hemispheres
  • failure of brainstem ARAS
  • both
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4
Q

confusion–what is it?

A

-orientation disturbed

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5
Q

delirium–what is it?

A

-hallucinations (visual)

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6
Q

obtundation–what is it?

A

-mental blunting, increased sleep, arouses to mild stimuli (voice)

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7
Q

stupor–what is it?

A

arouses only to noxious stimuli and not environmental

-only rudimentary awareness (purposeful motor responses)

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8
Q

coma–what is it?

A

-unarousable, unresponsive, unaware

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9
Q

persistent vegetative state

A
  • arousal, awarness
  • no reproducible response to stimuli
  • eyes may be open, eye movements
  • BP/pulse stable
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10
Q

akinetic mutism

A

-no spontaneous motor activity

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11
Q

locked in state

A
  • normal sensation/ cognition

- complete paralysis except vertical eye movements

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12
Q

hypertension–consider

A

-pheochromocytoma, drugs, increased ICP

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13
Q

hyperthermia consider

A

-infection, heat stroke, serotonin syndrome, pontine hemorrhage

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14
Q

breath odor–musty

A

hepatic failure

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15
Q

neuro exam–2 purposes

A
  • determine location and nature causing the impaired consciousness–anatomic level of brain involvement (supratentorial, subtentorial, diffuse)
  • narrow differential possibilities
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16
Q

broad categories of lesions that produce coma

A
  • supratentorial mass lesions–cause dysfunction in upper ARAS, cause downward herniation of brain to compress ARAS
  • infratentorial mass lesions–involve brainstem
  • diffuse/multifocal brain disease
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17
Q

supratentorial causes of coma

A
  • unilateral–subdural hematoma, brain abcess, tumor

- bilateral–subarachnoid hemorrhage, multiple infarcts, cerebral edema, acute hydrocephalus

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18
Q

subtentorial causes of coma

A
  • central pontine myelinolysis

- cerebellar hemorrhage/infarct, neoplasm, abcess

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19
Q

diffuse causes of coma

A

-hypoxia
-meningitis/encephalitis
-hypo/hyper-glycemia
-hyponatremia
-hepatic failure
-malignant hypertension
seizures (status epilepticus)

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20
Q

Neuro exam–essential elements

A
  • pupillary responses
  • corneal reflex
  • extraocular movements
  • cough/gag reflex
  • motor responses
  • resp pattern
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21
Q

Neuro exam–nearly essential elements

A
  • neck stiffness
  • carotid auscultation
  • fundoscopic exam
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22
Q

pupillary response–sympathetic path

A
  • hypothalamus
  • lower cervical cord
  • sympathetic chain
  • superior cervical ganglion
  • up carotid artery to CN V1, long cilicary nerve (dilator)
  • Mueller’s muscle
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23
Q

pupillary response–parasympathetic path

A
  • upper midbrain (edinger westphal nucleus)
  • CN III
  • ciliary ganglion
  • short ciliary nerve (constrictor)
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24
Q

symp and parasymp pathways for pupillary response–anatomically adjacent to?

A
  • ARAS

- absent or unequal responses imply brainstem lesion!!

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25
Q

dilated pupil on 1 side

A

-parasymp (CN III)

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26
Q

dilated pupil bilaterally

A
  • b/l lesion to CN III
  • post ictal
  • barbiturate intoxication
27
Q

constricted pupil

A

-symp dysfunction

28
Q

pinpoint pupil

A
  • pontine lesion
  • opiates
  • pilocarpine (3Ps)
29
Q

midposition and unreactive pupil

A

symp and parasymp (midbrain)

30
Q

frontal gaze, pontine gaze

A
  • frontal–deviate eyes to opp side

- pontine–deviate eyes to same side

31
Q

roving–conjugate, dysconjugate

A
  • conjugate–brainstem intact

- dysconjugate–brainstem lesion

32
Q

conjugate deviation at rest–hemispheric lesion

A
  • destructive–toward lesion

- irritative-away from lesion

33
Q

conjugate deviation at rest–brainstem lesion

A

-destructive–away from lesion

34
Q

oculocephalic maneuver (dolls eyes)

A

Mid pons!

  • CN 3,4,6
  • horizontal/vertical head rotation–eyes move opposite
35
Q

caloric (oculovestibular) reflex

A 
Lower pons!
-irrigate TM with cold water
-eyes deviate to irrigated side
-eye deviate downward if b/l irrigation
(brainstem intact!)
36
Q

decorticate?

A

arms flexed, legs extended

-hemispheric/ corte lesion

37
Q

decerebrate

A

all extremities extended

-brainstem

38
Q

flaccid?

A

pontomedullary or metabolic

39
Q

Cheynes Stokes

A
  • b/l hemispheres or diencephalon

- crescendo-decrescendo breathing pattern–hyperpnia alternating with apnea

40
Q

stupor and coma–4 broad categories

A
  • supratentorial
  • subtentorial
  • diffuse/metabolic
  • psychiatric unresponsiveness
41
Q

supratentorial mass lesions–characteristics

A
  • focal!
  • neuro signs–1 anatomic location
  • progression of signs rostral to caudal
  • motor signs–asymmetric
42
Q

herniation syndromes caused by?

A

expanding supratentorial mass lesions

-displace brain tissue–rostral to caudal progression

43
Q

uncal transtentorial

A

uncus under tentorium

-compress CN III, contralateral brainstem (ipsilateral hemiparesis), resp abnormalities

44
Q

central transtentorial

A

herniate into foramen magnum

-resp arrest, death

45
Q

cingulate gyrus

A

-herniates under falx

46
Q

subtentorial mass lesions characteristics

A
  • localizing brainstem signs preceed coma–always include oculovestibular abnormality (eye movement)
  • CN palsies usually present
  • bizarre respiratory patterns
47
Q

diffuse/metabolic characteristics and causes

A
  • confusion, stupor precede motor signs
  • motor signs symmetrical
  • pupillary reactions preserved!!
  • asterixis (liver flap-flaps wrist down and up), myoclonus
  • acid-base imbalance
hepatic/renal failure
-hyper/hypoglycemia
-hypoxia
electrolyte imbalance--hyper/hyponatremia, calcium
-sepsis
48
Q

global cerebral ischemia

A
  • blood flow inadequate to meet metabolic requirements of brain (cardiac, pul arrest)
  • ranges from reversible to brain death
49
Q

global cerebral ischemia reversible when?

A

-

50
Q

prolonged ischemic episodes

A
  • comatose at least 12 hours

- lasting focal or multifocal motor, sensory, cognitive deficits

51
Q

persistent vegetative state

A
  • awake but functionally decorticate, unaware of surroundings
  • eye opening, eye movements, sleep-wake cycles
52
Q

brain death definition

A
  • irreversibility
  • complete cessation of brain function (including respirations but not heartbeat)
  • persistance
53
Q

irreversibility–what must be ruled out?

A

-cause of coma known–irreversible

sedative intoxication, hypothermia (

54
Q

cessation of brain function

A
  • unresponsiveness to all sensory input

- absent brainstem reflexes–respiratory responses absent 8-10 minutes after patients pCO2 rises to 60 mmHg

55
Q

absent brainstem reflexes

A
  • pupillary light reflex-2,3
  • dolls eyes, cold water irrigation–3,6,8
  • pain reflex, pinch supraorbital n–5,7
  • corneal reflex–5,7
  • gag reflex–9,10
56
Q

brain death–persistence

A
  • 6 hours with confirmatory isoelectric (flat) EEG
  • 12 hours without confirmatory EEG
  • 24 hours for anoxic brain injury without confirmatory EEG
57
Q

manage comatose patients–1st steps

A
  • A-patent airways
  • B-breathing, oxygenation
  • C-circulation, bleeding
58
Q

manage comatose patients–next steps

A
  • history, exam, EKG
  • glucose, thiamine
  • antidote
  • adjust body T
  • control agitation
  • stop seizures if present
59
Q

manage comatose patients–Lab evaluation

A
  • venous blood–glucose, electrolytes, BUN/creatinine, osmolality, drug screen, liver function, ammonia, coagulation studies, blood cultures
  • arterial blood–pH, pO2, pCO2, HCO3, HbCO
  • urine–UA, culture, drug screen
  • if febrile–blood cultures
  • if stiff neck–LP after CT
60
Q

manage comatose patient–diagnostic testing

A
  • non-contrast CT (blood, space occupying lesion)
  • LP (xanthochromia–hemorrhage, infection)
  • MRI (posterior fossa, infarct)–not done right away!
  • EEG–if expect seizures
61
Q

manage comatose patient–specific interventions–reduce elevated intracranial P

A
  • elvate head of bed
  • intubate/hyperventilate to PCO2 of 20 mm (constricts BVs)
  • mannitol for ischemic lesions (hyperosmolar conc–will suck water/edema out of brain)
  • decadron for tumor, abcess, cerebral hemorrhage
  • Lasix–for dehydration
62
Q

manage comatose patient–specific interventions–treat seizures

A
  • lorazepam

- phenytoin

63
Q

glascow coma sclae

A

(3-15)

  • eye opening–1-4
  • best verbal response-1-5
  • best motor response-1-6
64
Q

KEY to accuracy in diagnosis and management lies in 2 steps

A
  • physical signs–determine anatomic level of brain involvement
  • determine supratentorial, subtentorial, or metabolic

NS2 Test 3 (14 decks)

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