Stupor and Coma

Question 1

What causes coma?

Answer 1

• BL hemisphere dysfunction
• brainstem dysfunction

1 of 2 OR both to qualify

Question 2

What is consciousness?

Answer 2

total awareness of self and environment

requires arousal (alert) and awareness (context)

Question 3

Impaired consciousness means:

Answer 3

• diffuse impairment of both hemispheres
• failure of brainstem ARAS

or both

Question 4

What supratentorial entities can cause unilateral hemisphere deficits that have mass effect–> affects other hemisphere with potential stupor/coma?

Answer 4

intracerebral hemorrhage

Large MCA infarct

subdural/epidural hematoma

brain abscess

neoplasm

Question 5

What supratentorial entities can cause bilateral hemisphere deficits with potential stupor/coma?

Answer 5

subarachnoid hemorrhage

multiple infarcts

venous thrombosis

cerebral edema

acute hydrocephalus

multiple mets

Question 6

What infratentorial entities can cause stupor/coma?

Answer 6

anything in brainstem

cerebellar problems that can mass effect to brainstem

Question 7

Essential parts of neuro exam

Answer 7

pupillary responses

corneal reflex

extraocular movements

cough/gag reflex

motor responses

respiratory pattern

nearly essential:
neck stiffness
carotid auscultation
funduscopic exam

Question 8

Pupils in coma are normally_____

Answer 8

normal or small

if dilated, think uncal herniation or something that is knocking out parasympathetics (CN3)

Question 9

If pupil enlarged on one side, the defect is _____

Answer 9

parasympathetic dysfunction (CN III)

Question 10

If pupil enlarged BL, the defect is _____

Answer 10

BL CN III lesion

post-ictal, intoxications

Question 11

If pupil is constricted, the defect is _____

Answer 11

sympathetic dysfunction (usually d/t hypothalamus, carotid)

Question 12

If pupil is pinpoint the defect is _____

Answer 12

pontine lesion

opiates, pilocarpine

3Ps: Pontine lesion, oPiates, Pilocarpine

Question 13

If pupil is midposition and unreactive, the defect is _____

Answer 13

sympathetic and parasympathetic

midbrain -

Question 14

Match decorticate/decerebrate to hemisphere or brainstem

Answer 14

decorticate–> prob with hemispheres

decerebrate–> prob with brainstem

Question 15

Define brain death

Answer 15

legal death

irreversible

complete cessation of brain function (no resp but can have heart beat)

persists

unresponsive to all sensory input, cerebral, cerebellar and brainstem responses

Question 16

What is the gold standard for declaring brain death?

Answer 16

apnea test

hyperoxygenate patient (100%) then turn off ventilator to see if they take a breath (if do, not brain dead)
--> watch for 8-10 minutes and check blood gas (if pCO2 rises to 60 while O2 100%, can confirm brain death)

Question 17

If you have a patient that is potentially in a coma with a stiff neck and they have a F with normal blood cultures and CT, what is the next step?

Answer 17

LP

they may have meningitis that is causing F