Stupor and Coma - Sachen Flashcards by Andrew Herrmann

Impaired consciousness means what?

1. Diffuse or bilateral hemisphere involvement
OR
2. Brainstem ARAS involvement
OR
3. BOTH

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Stupor

Arouses only to noxious stimuli (purposeful motor responses only)

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Locked-In state

Aroused and aware, complete paralysis except vertical gaze

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Akinetic mutism

Appears aroused but not aware, no spontaneous motor activity

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Neck stiffness causes

Meningitis, sub-arachnoid hemorrhage

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Acne cause?

Long-term anti-epilepsy drugs

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Dark pigmentation in creases of hands/skin

Addison’s disease

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Edema

Hepatic or renal failure

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Purpura

Meningococcal meningitis

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Needle marks

Drug OD

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Rash

Meningitis, viral encephalitis, rickettsia

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Musty breath

Hepatic failure

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Fruity odor

Ketoacidosis

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3 categories of causes of coma

Supratentorial mass (pressure-producing)
Infratentorial lesions involving brainstem
Diffuse or multifocal disease

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Unilateral hemisphere coma causes (5)

Intraparenchymal emorrhage
MCA infarct
Hematoma
Abscess
Neoplasm

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Bilateral hemisphere coma causes (6)

Subarachnoid hemorrhage
Multiple infarcts
Venous thrombosis
Cerebral edema
Hydrocephalus
Metastases

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Intratentorial coma causes

Pontine hemorrhage (–> hyperthermia)
Basilar artery occlusion
Central pontine myelinolysis (hyponatremia cure)
Cerebellar hemorrhage/infarct/neoplasm/abscess
Brainstem neoplasm/infarct

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Diffuse causes of coma

Hypoxia, hypoglycemia, hyperglycemia (NON-KETOTIC), hyponatremia, hepatic failure (EtOH, hepatitis), malignant hypertension, toxins, drugs, seizures

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ESSENTIAL elements to neural exam (5)

Pupillary responses
EOM movements
Motor response
Corneal reflex
Respiratory pattern

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ALMOST essential elements to neural exam (4)

Neck stiffness
Cough/gag reflex
Fundoscopic exam (papilledema)
Carotid auscultation

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Sympathetic path from brain to pupil

SO, what test result could mean a lesion along this path?

Hypothalamus, IMLCC, superior cervical ganglion, up carotid artery, CN V1, long ciliary nerve (dilator)

Constricted pupil

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Parasympathetic path from brain to pupil

E-W nucleus (midbrain), CN 3, ciliary ganglion, short ciliary nerve (constrictor)

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Pupillary reflexes and coma

Nuclei/tracts for pupils and ARAS are adjacent in brainstem, thus lesion could affect both

Key to brainstem localization of lesion

Absent or unequal pupillary responses

Pinpoint pupils

Pontine lesion or opiates (heroin, morphine)

Pupils midline and unreactive

Midbrain lesion

The 4 P's of Pinpoint Pupils

Pontine, oPiates, Pilocarpine, Phenoparbitol

Frontal gaze center lesion

Eyes deviate towards lesion

Pontine gaze center lesion

Eyes deviate away from lesion

Dysconjugate roving eye movements

Brainstem lesion

Ping-pong nystagmus

Bi-hemispheric or midbrain

Converge/rapid jerk back nystagmus

Mesencephalon

Bobbing nystagmus (rapid down, slow up)

Pons

Dipping nystagmus (slow down, rapid up)

Bihemispheric

Caloric test - eyes deviate towards stimulus

Unilateral PONS

Caloric test - eyes deviate down

Bilateral PONS

Decorticate posture | Meaning?

Arm(s) flexed, leg(s) extended | Hemispheric lesion

Decerebrate posture | Meaning?

All extremities extended | Brainstem lesion

Flaccid paralysis

Pontomedullary or metabolic

Hyper breathing alternating with no breathing | Meaning?

Cheynes-Stokes | Bilateral hemispheres or diencephalon

Sustained hyperventilation

Midbrain

Long inspiration followed by 2-3 second pause, then expiration

Apneustic - many causes

Ataxic/irregular breathing

Medullary respiratory centers

Blown pupil --> ipsilateral hemiparesis --> respiratory and postural abnormalities

Uncal (transtentorial) herniation progression

Brainstem dysfunction signs (dysequilibrium, dysarthria, diplopia, vertigo), CN palsies, weird respirations

Subtentorial mass lesion

``` Confusion and stupor LATER, symmetrical motor signs Normal pupils Asterixis, tremor, seizures Fluctuating consciousness ```

Diffuse or metabolic cause

Asterixis

Raise straight arm with wrist extended --> wrist starts to do flapping motion - Indicates METABOLIC disorder

``` Unpredictable oculocephalic (Dolls' eye) tests Dizzy and vomiting w/ oculovestibular (Caloric) tests ```

Psychiatric unresponsiveness

Causes of global cerebral ischemia

Cardiac arrest or pulmonary arrest

Cause of persistent vegitative state

Prolonged global cerebral ischemia

Brain death

No brain function, including respirations Heartbeat still active Unresponsive Absent brainstem reflexes

Things that can mimic brain death

Shock, sedative intoxication, neuromuscular blockade, hypothermia (

Initial steps for comatose treatment

ABCs, Hx, exam, EKG, glucose and thiamine, antidote, adjust body temp, control agitation and seizures

How to reduced increased ICP?

``` Elevate head of bed Intubate and hyperventilate to PCO2 of 20mm Mannitol for ischemic lesions Decadron for masses or hemorrhage Maybe Lasix (diuretic) ```

How to treat seizures?

Lorazepam or Phenytoin