III- Coma and Intracranial Pressure

Question 1

● Greatest danger in neurologic disease

Answer 1

increased intracranial pressure

Question 2

PROGRESSION OF INCREASED ICP

Answer 2

1. Headache – very early sign
2. Vomiting – progression; ICP is worsening
3. Decrease sensorium
4. Herniation
5. Brain death

Question 3

EARLY SIGNS OF INCREASING INTRACRANIAL PRESURE:

Answer 3

● Cushing’s phenomenon
o Can occur before other clinical signs of ICP occur
o ↑ ICP = ↑ BP + ↓ HR

Question 4

LEVEL OF SENSORIUM (FROM HIGH TO LOW)

Answer 4

1. Alert/Awake
2. Drowsy, Lethargic
3. Stupor
4. Coma or Unconscious

Question 5

(highest level of sensorium) – eyes
open spontaneously

Answer 5

awake/alert

Question 6

eyes open to verbal stimulation
or light touch

Answer 6

drowsy/lethargic

Question 7

eye opening to pain stimuli

Answer 7

stupor

Question 8

no eye opening no matter
what stimulus (has different levels:)

Answer 8

unconscious/coma

Question 9

when you give a pain stimulus, px can locate the
stimulus and try to remove it

Answer 9

Purposeful withdrawal to pain (lightest coma)

Question 10

try to move
but cannot locate where the pain stimulus is given

Answer 10

Non-purposeful withdrawal to pain

Question 11

flexion response of UE and
LE extension

Answer 11

Decorticate posturing

Question 12

extensor response where
UE are extended

Answer 12

Decerebrate posturing

Question 13

no movement when you
stimulate the px

Answer 13

Unresponsive coma

Question 14

pressure of all the substances inside the
cranium (skull)

Answer 14

Intercranial Pressure

Question 15

amount of blood that goes up
to the brain

Answer 15

Cerebral blood flow

Question 16

How many mL of blood enters the brain in every minute?

Answer 16

700 mL

Question 17

power or force that drives blood
into the brain

Answer 17

Cerebral perfusion pressure

Question 18

ICP is composed of the ff:

Answer 18

1. Brain substance
2. Blood volume
3. CSF

Question 19

brain parenchyma

Answer 19

brain substance

Question 20

the amount of blood inside the
arteries, arterioles, venous systems and sinuses

Answer 20

blood volume

Question 21

inside the
ventricles or canals

Answer 21

CSF

Question 22

CAUSES OF INCREASED BRAIN PARENCHYMA

Answer 22

1. Cerebral edema (most common cause) – free water
2. Brain tumors – growth of new abnormal brain cells
3. Damaged neurons and glial cells that are swollen

Question 23

T or F
145 mL CSF can be accommodated by ventricles
and subarachnoid space

Answer 23

False: 135 mL

Question 24

T or F
blood inside all of the
arterioles, arteries, veins, and
sinuses can be 150 Ml

Answer 24

T

Question 25

Defined as free water in certain areas or free spaces
of the brain

Answer 25

Edema

Question 26

TYPES OF EDEMA

Answer 26

1. Vasogenic
2. Cytotoxic
3. Interstitial Edema

Question 27

extracellular accumulation of fluid from
disruption of the blood brain barrier
o From the blood vessel
o Common in tumors and bleeding into the brain

Answer 27

Vasogenic

Question 28

– intracellular accumulation of fluid
causing the cell to swell
o Located in the neuron or glial cells
o Fluid is inside the cells
o Seen in infarcts

Answer 28

Cytotoxic

Question 29

outflow of CSF into the
interstitial area of the brain
o Flow of free water or CSF goes out due to high
pressure in the ventricles into the interstitial
spaces

Answer 29

interstitial edema

Question 30

Openings of herniation

Answer 30

1. Tentorial Notch
2. Foramen Magnum

Question 31

where the diencephalon
connects with the midbrain (tentorium cerebelli
that separates the cerebral hemisphere with the
diencephalon on top, while the brainstem and
cerebellum are below)

Answer 31

tentorial notch

Question 32

where medulla connects to
the cervical spinal cord
● Uncus is the one that enters the tentorial notch
because the temporal lobe is above the tentorium
● Tonsils of cerebellum enters the foramen magnum

Answer 32

Foramen Magnum

Question 33

it is the uncus of the medial part
of the temporal lobe enters the tentorial notch

Answer 33

Uncal Herniation

Question 34

SIGNS OF UNCAL HERNIATION

Answer 34

o Decreased sensorium
o CN 3 damage (which is responsible for moving the
eyes inward or adduction, pupillary constriction,
and eyelid opening)
a. Ipsilateral medial rectus palsy (2
nd pic)
b. Ipsilateral dilating pupil (not reactive to light –
NRTL) (1
st pic)
c. Ipsilateral ptosis
● All of the symptoms of CN 3 damage (a and b)
should go with decreased sensorium for it to be
considered as uncal herniation

Question 35

If uncus come down left and right (both side of the
brain)

Answer 35

central herniation

Question 36

SIGNS OF CENTRAL HERNIATION

Answer 36

o Decreased
sensorium
o Bilateral medial
rectus palsy
o Bilateral
dilating
non-reactive
pupil

Question 37

Tonsils from medial part of cerebellum will come
down and pass through the foramen magnum

Answer 37

Tonsillar Herniation

Question 38

SIGNS OF TONSILLAR HERNIATION

Answer 38

● At the lower medulla is the inspiratory center thus
one sign is apnea
● Apnea = absence of breathing
● Decreased sensorium
● When patient has
decreased sensorium and
suddenly stops breathing =
(+) tonsillar herniation
● Increased in ICP in the
infratentorial area (either
bleeding in the cerebellum
or brainstem)
● Increased ICP – doctors
perturbate and put a tube
in right away and connect them to the ventilator
o If not, patients will die due to cardiac death
immediately

Question 39

where part of the hemisphere goes
under the falx cerebr

Answer 39

Falx herniation

Question 40

Control of ICP

Answer 40

1. Elevate head 15-30 degrees
2. Control fever aggressively
3. Ventilatory Support (Controlled Respiration)
4. Osmotic Diuretics mannitol/ hypertonic saline
5. Dexamethasone (steroid for vasogenic edema)