A 8 - Examination of the unconscious patient

Question 1

Observation when examining unconcious patient

Answer 1

1) Semiologic phenomena of sleep (does it look like the patient is sleeping?)
2) Reaction to external stimulus
3) Spontaneous activity

● Glasgow-coma scale for estimation of prognosis (3-coma/death,
15-fully alert and oriented)

● Life-threatening circulatory or respiratory disorders should be
excluded/treated before neurological exam.

● Check for signs of external trauma on the skull

● Observe eye position, brainstem reflexes (incl. pupillary reflex), position and muscle tone

● Apply painful stim., note elicited motor reactions

● Examine deep tendon and superficial reflexes and pyramidal
signs

Question 2

Signs and symptoms of an unconscious patient

Answer 2

Ocular symptoms
Vestibular reactions
Motor phenomena

Question 3

Signs and symptoms of an unconscious patient:
Ocular symptoms

Answer 3

Pupils and pupillary reactions

Gaze disorders

Question 4

What are the Pupils and pupillary reactions?

Answer 4

● Pupillary constriction
● Pupillary dilation
● Fixed, moderately dilated pupils
● Anisocoria
● Pinpoint pupils

Question 5

What is papillary constriction?

Answer 5

It is light reactions are preserved!

○ Bilateral → bilateral hypothalamus and diencephalon damage

○ Horner’s syndrome (miosis, ptosis, anhidrosis) → unilateral damage

Question 6

What is Pupillary dilation?

Answer 6

NO pupillary light reactions, hippus may be seen → tectum lesions

Question 7

Fixed, moderately dilated pupils indicate

Answer 7

lesion below tectum

Question 8

what is Anisocoria

Answer 8

pupil on the side of oculomotor n. compression is larger → transtentorial herniation

Question 9

what is Pinpoint pupils

Answer 9

pontine lesions disrupting descending SY fibers

Question 10

What are the Gaze disorders?

Answer 10

Disorder of vertical gaze
Skew deviation
Randomly wandering eyes
Persistent upward deviation
Persistent downward deviation
Bell’s phenomenon

Question 11

what are the disorder of vertical gaze?

Answer 11

downward rotation → damage to rostral interstitial nucleus of medial longitudinal fascicle

Question 12

what is skew deviation?

Answer 12

eyes diverge in vertical direction, one rotated down, the other up → caudal part of brainstem and meso-diencephalon damage

Question 13

what does Randomly wandering eyes indicate?

Answer 13

persistent vegetative phase

Question 14

what does Persistent upward deviation indicates?

Answer 14

global cerebral ischemia

Question 15

what is Bell’s phenomenon?

Answer 15

reflex upward movement of the eye when closed may be elicited in a somnolent patient if tegmentum and CNIII are intact

Question 16

what are the Vestibular reactions?

Answer 16

• Vestibulo-ocular (doll’s eye) reflex
• Reaction to stimulation w/ cold water into ear

Question 17

what is Vestibulo-ocular (doll’s eye) reflex?

Answer 17

elicited by turning the pt. head to the R and L, back and forward → eyes will move conjugately in opposite direction

● If they move together with the head (fixed) → brainstem damage

Question 18

descirbe the Reaction to stimulation w/ cold water into ear?

Answer 18

● Regular nystagmus w/ a quick and slow component, beating towards contralat. ear

● Conjugate deviation towards stim. ear w/ only a few nystagmoid jerks towards contralat. ear

● Conjugate deviation towards stim. ear, but no quick component

● The eyes don’t move at all → severe brain stem injury

Question 19

What the Motor phenomena includes?

Answer 19

1. Motor reactions elicited by painful stimuli
2. Possible findings

Question 20

in the motor phenomena, what Motor reactions elicited by painful stimuli may be?

Answer 20

● Appropriate, coordinated withdrawal
● Inappropriate movements
● Abnormal increase of muscle tone

Question 21

in the motor phenomena, what are the pissible findings?

Answer 21

● Decorticate posture (flexion of arms and extension of legs, increasing w/ painful stim.) → bilat. diencephalic lesion

● Unilat. adductor-extensor tone increase → ipsilat. thalamus lesion

● Decerebrate posture (increased extensor-adductor tone in all limbs, increased adductor-torsional tone w/ painful stim.) → mesencephalon damage

● Increased flexor tone in legs, flaccid/increased extensor tone in arms → damage to pons