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Neuro II Final > Stupor And Coma (Sachen) > Flashcards

Stupor And Coma (Sachen) Flashcards

1
Q

Define consciouness

A

Total awareness of self and environment
Requires:
-arousal: level of alertness, ability to interact with environment
-awareness (content): sum of cognitive mental functions, “know what’s going on”

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2
Q

Describe consciousness and brain structures

A

Depends on arousal of cerebral cortex by brainstem ascending reticular activating system (ARAS)

  • input from many sensory systems
  • projects to hypothalamus, thalamus, cortex
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3
Q

What does impaired consciousness mean?

A

Diffuse or bilateral impairment of both cerebral hemispheres
Failure of brainstem ARAS
Both

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4
Q

Define confusion

A

Attention deficit, orientation disturbed, stimuli misinterpreted

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5
Q

Define delirium

A

Disorientation, stimuli misinterpreted, hallucinations (visual)

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6
Q

Define obtundation

A

Mental blunting, increased sleep, arouses to mild stimuli (voice)

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7
Q

Define stupor

A

Arouses only to noxious stimuli and not environmental, only rudimentary awareness (purposeful motor responses)

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8
Q

Define coma

A

Unarousable, unresponsive, unaware

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9
Q

Describe persistent vegatative

A

+arousal
+awareness
no reproducible response to stimuli, eyes may be open, roving eye movements, BP/pulse stable

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10
Q

Describe akinetic mutism

A

Appears +arousal
(-) awareness
No spontaneous motor activity

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11
Q

Describe locked in state (Monte Cristo Syndrome)

A

+arousal
+awareness
Normal sensation/cognition but complete paralysis except for vertical eye movements

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12
Q

Describe psychogenic state

A

+/altered arousal

+/altered changing/inconsistent physical examination

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13
Q

What does assessment of comatose patient include?

A 
History
General medical exam
Neurological exam
Laboratory evaluation
Diagnosis and treatment
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14
Q

Describe history of comatose pt

A 
From family, EMTs, witnesses
How and when pt was found
Sudden or gradual onset
Prior illnesses (esp vascular) and medications
Any recent symptoms (fever, confusion)
History of substance abuse
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15
Q

Describe general exam of comatose pt

A 
Vital signs (resp rate and pattern)
Skin
Breath odor
Signs of trauma: raccoon eyes, battle sign, CSF leak (otorrhea, rhinorrhea)
Neck stiffness: meningitis, SAH
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16
Q

Describe considerations for hyper/hypotension and hyper/hypothermia in comatose pt

A

Hypertension: pheochromocytoma, drugs (amphetamine, cocaine, phenyclidine), increased ICP, PRES

Hypotension: Addison’s, sepsis, drugs (Beta-blocker, Ca chanel blocker, TCA’s, Li, sedatives, organophosphates, opioids, methanol), progression to brain death

Hyperthermia: infection, heat stroke, drugs (amphetamines, TCA’s cocaine, salicylates, neuroleptics), serotonin syndrome, central (pontine hemorrhages)

Hypothermia: hypothyroid, hypoglycemia, exposure, drugs (opioids, sedatives, barbiturates, phenothiazine, Et-OH)

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17
Q

Describe skin considerations in comatose pt

A

Diaphoresis: thyroid storm, decrease BS, drugs (sympathomimetics, cholinergics)
Dry: hypothyroid, drugs (anticholinergics, TCAs)
Acne: long term antiepileptic use
Butterfly rash: systemic lupus
Dark pigmentation: Addison’s disease
Cold, puffy, yellowish: Myxedema coma
Edema: acute hepatic or renal failure
Purpura: meningococcal meningitis, TTP, DIC, vasculitis, aspirin OD
Rash: meningitis, viral encephalitis, rickettsia
Needle marks: Drug OD

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18
Q

Describe breath odor considerations in comatose pt

A

Dirty restroom: uremia
Fruity: ketoacidosis
Musty: hepatic failure
Onion: paraldehyde (rarely used anymore to treat seizures)
Garlic: organophosphates (insecticides, herbicides, sarin)

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19
Q

What is the purpose of neurological examination of comatose pt?

A
  1. Determine location and nature of process that is causing impaired consciousness with emphasis on anatomic level of brain involvement (supratentorial, subtentorial, or diffuse)
  2. Narrow differential possibilities
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20
Q

What broad category of lesions produce coma?

A
  1. Large, pressure producing supratentorial mass lesions
    - cause dysfunction in upper ARAS
    - cause downward herniation of brain to compress ARAS
  2. Infratnetorial mass lesions that involve brainstem
  3. Diffuse or multifocal brain disease
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21
Q

Describe unilateral hemisphere (mass effect) supratentorial causes of coma

A 
Intracerebral hemorrhage
Large MCA infarct
Subdural hematoma
Epidural hematoma
Brain abscess
Neoplasm
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22
Q

Describe bilateral hemisphere supratentorial causes of coma

A 
Subarachnoid hemorrhage
Multiple infarcts
Venous thrombosis
Cerebral edema
Acute hydrocephalus
Multiple metastases
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23
Q

What are subtentorial causes of coma?

A 
Pontine hemorrhage
Basilar artery occlusion
Central pontine myelinolysis
Cerebellar hemorrhage/infarct
Cerebellar/brainstem neoplasm
Cerebellar abscess
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24
Q

What are diffuse causes of coma?

A 
Vasculitis
Hypoxia
Hypercapnia
Meningitis/encephalitis
Hypoglycemia
Hyperglycemia (nonketotic)
Hyponatremia
Acute hypothyroidism
Hypercalcemia
Heptaic failure
Uremia
Malignant hypertension
Hypo/hyperthermia
Toxins
Drug intoxication
Drug withdrawal
Malignant neuroleptic syndrome
Seizures (esp status epilepticus)
25
What are the essential and nearly-essential elements of the neuro exam of comatose pt?
``` Essential: Pupillary responses Corneal reflex Extraocular movements Cough/gag reflex Motor responses Respiratory pattern ``` Nearly-essential: Neck stiffness Carotid auscultation Funduscopic examination All of these should be performed in stepwise manner
26
Describe pupillary responses
1. Sympathetic/parasympathetic balance determines size - sympathetic path: hypothalamus->lower cervical cord->sympathetic chain->superior cervical ganlgion->up carotid a. To CN V(I), long ciliary nerve (dilator), Mueller's muscle - parasympathetic path: upper midbrain (Edinger Westfall nucleus)->CNIII->ciliary ganglion->short ciliary nerve (constrictor) 2. Nuclei/tracts controlling pupils are anatomically adjacent to ARAS. Therefore, absent or unequal responses imply brainstem lesion
27
With anisocoria: which is the abnormal pupil?
Rule of thumb: If it's the large pupil, it should fail to constrict to light. If it's the small pupil, it should fail to dilate in dark
28
Describe the rules of thumb for pupillary responses
Enlarged on one side: parasympathetic dysfunction (usually CNIII) Enlarged bilaterally: bilateral CNIII lesion, post ictal, barbiturate intox Constricted: sympathetic dysfunction (hypothalamus, carotid) Pinpoint: pontine lesion, opiates pilocarpine -Three P's of pinpoint pupils: Pontine lesion, oPiates, Pilocarpine Midposition and unreactive: sympathetic and parasympathetic (midbrain)
29
Interpretation of pupillary signs may be confused by what?
``` Atropine/scopolamine: dilated, fixed Opiates: pinpoint, +/- reactive Pilocarpine: pinpoint Glutethimide: dilated, fixed, unequal Hypothermia, anoxia, ischemia: possible dilated, fixed, unequal ```
30
Describe extraocular movements in neuro exam of comatose pt
Conjugate gaze depends on intact CN III, IV, and VI, their nuclei, and interconnections Frontal gaze centers deviates eyes to opposite side Pontine gaze centers deviate eyes to same side
31
Describe spontaneous roving extraocular movements
Conjugate: implies brainstem intact Dysconjugate: implies brainstem lesion
32
Describe spontaneous conjugate deviation at rest of extraocular movements
Hemispheric lesion: Destructive: toward lesion Irritative: away from lesion Brainstem lesion Destructive: away from lesion
33
Describe the types of nystagmus and indicated lesions
Ping-pong (right-left deviation every few seconds): bihemispheric, midbrain Convergence (slow abduction with rapid jerk back): mesencephalon Retractory (retraction orbit): mesencephalon Bobbing (rapid down, slow up): pons Dipping (slow down, rapid up): bihemispheric
34
Describe oculocephalic maneuver (Doll's eyes)
Reflexive Tests mid-pons Used to assess CN III, IV, and VI Passive horizontal head rotation: eyes move horizontally opposite Passive vertical head rotation: eyes move vertically opposite Be sure neck is stable Overridden in alert patient
35
Describe Caloric (oculovestibular) reflex
Reflexive Lower pons Otoscopic exam: be sure canal clear and TM intact Irrigate TM with cold (usually) or warm water Cold water irrigation with intact brainstem causes: Eyes to deviate to irrigated side if unilateral irrigation Eyes to deviate downward if bilateral irrigation
36
Describe motor responses in neuro exam of comatose pt
Purposeful: follows commands, localizes pain Reflexive: - decorticate: arms flexed, and legs extended (hemispheric) - decerebrate: all extremities extended (brainstem) - flaccid: pontomedullary or metabolic
37
Describe respiratory patterns in comatose pt
Cheynes-Strokes: hyperpnia regularly alternating with apnea (bilateral hemispheres or diencephalon). Seen in many disorders ranging from metabolic to structural Central neurogenic hyperventilation: midbrain Apneustic breathing: long inspiration followed by apnea (mid/low pons). Seen in structural lesions and anoxia, hypoglycemia, meningitis Ataxic: completely irregular (medullary respiratory centers)
38
Describe supratentorial mass lesions
Initial signs usually focal Neurological signs at any given time point to one anatomic location Progression of signs is rostral to caudal Motor signs are often asymmetric
39
Describe herniation syndromes
Caused by expanding supratentorial mass lesions Effect is to displace brain tissue into adjacent intracranial compartments (so called rostral to caudal progression of herniation)
40
Describe uncal transtentorial herniation
Herniation of uncus under edge of tentorium, compressing CN III (ipsilateral dilated pupil, poor EOM, ptosis), then contralateral brainstem (ipsilateral hemiparesis), then respiratory abnormalities, posturing, fixed pupils, and death
41
Describe central transtentorial herniation
Herniation into foramen magnum leads to early coma, small pupils, normal EOMs, posturing and later bilateral fixed pupils, respiratory arrest, and death
42
Describe cingulate gyrus herniation
Herniates under falx
43
Describe subtentorial mass lesions
History: preceding brainstem dysfunction usual (disequilibrium, dysarthria, dysphagia, diplopia, vertigo) but may be sudden onset of coma Localizing brainstem signs precede or accompany onset of coma and almost always include a form of oculovestibular abnormality Cranial nerve palsies usually present Bizarre respiratory patterns common
44
Characterize diffuse/metabolic coma
Confusion and stupor commonly precede motor signs Motor signs are usually symmetrical Pupillary reactions are usually preserved Asterixis, myoclonus, tremor, seizures common Acid-base imbalance with hyper or hypoventilation frequently seen Level of consciousness may fluctuate
45
Describe global cerebral ischemia
Occurs whenever blood flow is inadequate to meet metabolic requirements (oxygen and glucose) of brain, as in cardiac or pulmonary arrest Result is spectrum of disorders, ranging from reversible encephalopathies to brain death
46
Describe brief (
Commonly reversible encephalopathies, generally after 12 hours or less of stupor or coma Anteograde and/or retrograde amnesia can occur Recovery often occurs within 7-10 days but may be delayed by 1 month or longer
47
Describe prolonged ischemic episodes
Focal cerebral dysfunction Patients are usually comatose for at least 12 hours and may have lasting focal or multifocal motor, sensory, and cognitive deficits
48
Describe persistent vegetative state
Awake but functionally decorticate and unaware of surroundings Eye opening, eye movements, sleep-wake cycles, and brainstem and spinal reflexes may remain intact
49
What does the definition of brain death imply?
Irreversibility Complete cessation of brain function (including respirations but not heartbeat) Persistence
50
Describe irreversibility of brain death
Cause of coma should be known. Must be adequate to explain clinical picture and must be irreversible Sedative intoxication, hypothermia (≤ 90F), neuromuscular blockade, and shock must be ruled out, since these conditions can produce a clinical picture that resembles brain death but are potentially reversible.
51
Describe cessation of brain function
Unresponsiveness: pt must be unresponsive to all sensory input, including pain and speech Absent brainstem reflexes: including pupillary, corneal, oculocephalic, and oculovestibular reflexes. Respiratory response are absent at 8 to 10 minutes after pt's pCO2 is allowed to rise to 60 mm Hg, while oxygenation is maintained with 100% O2 (apnea test)
52
Describe persistence of brain death
Criteria for brain death must persist for an appropriate length of time Six hours with a confirmatory isoelectric (flat) EEG, performed according to technical standards of AEES Twelve hours without confirmatory isoelectric EEG Twenty-four hours for anoxic brain injury without a confirmatory isoelectric EEG
53
Describe precautionary notes about brain death
State law may impose additional requirements such as - qualification of examiner - confirmation by second examiner Ancillary tests (EEG, angiography, nuc med scan) are not required unless there is uncertainty about diagnosis or apnea test cannot be performed. However, some countries do require them.
54
Describe the initial steps for management of comatose patient
A: Insure pt airways (spontaneous, mouth piece, ETT) B: insure breathing and adequate oxygenations (pulse oxy, O2, ABG) C: Insure adequate ciruclation and control any active bleeding (BP, P)-IV line, arterial line, ECG Stabilize neck, get C-spine films if trauma suspected Quick history (seizure, meds, drug use, trauma) Quick exam EKG to monitor for arrhythmias Give glucose (1 amp=25gms), thiamine (100 mg IM) Give specific antidote (Narcan) Adjust body temperature Control agitation Stop seizures if present
55
Describe laboratory evaluation of comatose pt
Venous blood: glucose, electrolytes (including calcium, phosphorus, magnesium), BUN/creatinine, osmolality, drug screen, liver functions, ammonia, coagulation studies, thyroid function, blood cultures Arterial blood: pH, pO2, pCO2, HCO3, HbCO Urine: UA, culture, drug screen If febrile: blood cultures If stiff neck: LP (after CT) with CSF for cell count, glucose, protein, gram stain, cultures (bacterial, viral, and fungal)
56
Describe diagnostic testing
Noncontrast head CT - acute blood - space occupying lesion LP - xanothochromia (SAH) - infection +/- MRI - posterior fossa - early infarct +/- EEG
57
What are specific interventions for comatose pt?
Reduce elevated intracranial pressure - elevate head of bed - Intubate and hyperventilate to PCO2 of 20 mm - use mannitol for ischemic lesions - use decadron for tumor, abscess, and perhaps cerebral hemorrhage - Lasix 20-40 mg IV possibly Treat seizures - lorazepam 2 mg IV q10-15 min up to 10 mg total - phenytoin 18 mg/kg load (about 1000 mgs) then 300 mg/day
58
Describe Glasgow Coma Scale 3-15
``` Eye opening: Never: 1 To pain: 2 To verbal: 3 Spontaneous: 4 ``` ``` Best verbal response: None: 1 Sounds: 2 Inapp words: 3 Disoriented; 4 Oriented: 5 ``` ``` Best motor response None: 1 Extensor: 2 Flexor: 3 Withdrawal: 4 Localizes: 5 Obeys: 6 ``` Sum and individual elements are important: eg GCS = 9, E2, V3, M5

Neuro II Final (17 decks)

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