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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
Q

What are the essential and nearly-essential elements of the neuro exam of comatose pt?

A 
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
Q

Describe pupillary responses

A
  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
Q

With anisocoria: which is the abnormal pupil?

A

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
Q

Describe the rules of thumb for pupillary responses

A

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
Q

Interpretation of pupillary signs may be confused by what?

A 
Atropine/scopolamine: dilated, fixed
Opiates: pinpoint, +/- reactive
Pilocarpine: pinpoint
Glutethimide: dilated, fixed, unequal
Hypothermia, anoxia, ischemia: possible dilated, fixed, unequal
30
Q

Describe extraocular movements in neuro exam of comatose pt

A

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
Q

Describe spontaneous roving extraocular movements

A

Conjugate: implies brainstem intact
Dysconjugate: implies brainstem lesion

32
Q

Describe spontaneous conjugate deviation at rest of extraocular movements

A

Hemispheric lesion:
Destructive: toward lesion
Irritative: away from lesion

Brainstem lesion
Destructive: away from lesion

33
Q

Describe the types of nystagmus and indicated lesions

A

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
Q

Describe oculocephalic maneuver (Doll’s eyes)

A

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
Q

Describe Caloric (oculovestibular) reflex

A

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
Q

Describe motor responses in neuro exam of comatose pt

A

Purposeful: follows commands, localizes pain

Reflexive:

  • decorticate: arms flexed, and legs extended (hemispheric)
  • decerebrate: all extremities extended (brainstem)
  • flaccid: pontomedullary or metabolic
37
Q

Describe respiratory patterns in comatose pt

A

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
Q

Describe supratentorial mass lesions

A

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
Q

Describe herniation syndromes

A

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
Q

Describe uncal transtentorial herniation

A

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
Q

Describe central transtentorial herniation

A

Herniation into foramen magnum leads to early coma, small pupils, normal EOMs, posturing and later bilateral fixed pupils, respiratory arrest, and death

42
Q

Describe cingulate gyrus herniation

A

Herniates under falx

43
Q

Describe subtentorial mass lesions

A

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
Q

Characterize diffuse/metabolic coma

A

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
Q

Describe global cerebral ischemia

A

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
Q

Describe brief (

A

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
Q

Describe prolonged ischemic episodes

A

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
Q

Describe persistent vegetative state

A

Awake but functionally decorticate and unaware of surroundings
Eye opening, eye movements, sleep-wake cycles, and brainstem and spinal reflexes may remain intact

49
Q

What does the definition of brain death imply?

A

Irreversibility
Complete cessation of brain function (including respirations but not heartbeat)
Persistence

50
Q

Describe irreversibility of brain death

A

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
Q

Describe cessation of brain function

A

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
Q

Describe persistence of brain death

A

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
Q

Describe precautionary notes about brain death

A

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
Q

Describe the initial steps for management of comatose patient

A

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
Q

Describe laboratory evaluation of comatose pt

A

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
Q

Describe diagnostic testing

A

Noncontrast head CT

  • acute blood
  • space occupying lesion

LP

  • xanothochromia (SAH)
  • infection

+/- MRI

  • posterior fossa
  • early infarct

+/- EEG

57
Q

What are specific interventions for comatose pt?

A

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
Q

Describe Glasgow Coma Scale 3-15

A 
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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