Stupor & Coma (Hon)

Question 1

Typical pathophysiolgy of coma

Answer 1

b/l hemisphere dysfunction or brainstem (ARAS) dysfunction or not (CANNOT be a unilateral brain problem)

Question 2

Two requirements needed for consciousness?

Answer 2

1. arousal - alertness
2. awareness - “know what’s going on”

Question 3

Consciousness depends on what system?

Answer 3

Ascending reticular activating system (ARAS)

Question 4

What are essential elements of the neurological exam in a patient you suspect to be in stupor or coma?

Answer 4

pupillary response (gives a lot of clues)
corneal reflex
extra ocular movements
cough/gag reflex
motor responses
respiratory pattern

Question 5

If the pupil is large in a coma patient, what should it fail to do in a pupillary response test?

Answer 5

fail to constrict to light

Question 6

If the pupil is small in a coma patient, what should it fail to do in a pupillary response test?

Answer 6

fail to dilate in the dark

Question 7

Anisocoria

Answer 7

abnormal pupil

Question 8

What are the three P’s of pinpoint pupils?

Answer 8

Pontine lesion
oPiates
Pilocarpine (cholinergic agonist used in glaucoma)

Question 9

Decorticate

Answer 9

arms flexed, legs extended (hemispheric) think cortical deCORTICATE

Question 10

Decerebrate

Answer 10

all extremities extended (brainstem)

Question 11

Uncal trantentorial herniation

Answer 11

herniation of uncut under edge of tentorium compressing CN III and c/l brainstem leading to respiratory abnormalities fixed pupils and death

Question 12

What would the patient present with if they were suffering from an uncal trantentorial herniation?

Answer 12

I/l dilated pupil and poor movement of extra ocular muscles (compressing of CN III); I/l hemiparesis (compressing c/l brainstem); respiratory abnormalities posturing, fixed pupils and death

Question 13

Central transtentorial herniation

Answer 13

herniation into the foramen magnum leads to early coma, small pupil, normal EOMs, posting and later b/l fixed pupils, respiratory arrest and death

Question 14

Definition of brain death

Answer 14

irreversibility - not reversible
complete cessation of brain function - unresponsiveness and absent brainstem reflexes (apnea test)
persistence - 6 hours with confirmatory flat EEG

Question 15

What is the best test to perform to diagnose complete cessation of brain function in a brain dead patient?

Answer 15

apnea test