Clinical Approach to Stupor and Coma Flashcards
(24 cards)
What is Consciousness?
What are the two requirements of consciousness?
total awareness of self and environment
Requirements: Arousal and Awareness
How do you define “impaired consciousness?
- Diffuse or bilateral impairment of both cerebral hemispheres
- Failure of brainstem ARAS
- Both
What type of hallucinations would you expect in a patient with a neurologic issue?
Visual
auditory would mean psychiatric issue
Describe a Persistent Vegetative state
Positive arousal, but no awareness.
No reproducible response to stimuli, eyes may be open; roving eye movements; unaware; BP/pulse stable
Describe Akinetic Mutism
Appears aroused, lacks awareness
no spontaneous motor activity
Describe Locked In State (Monte Cristo)
Positive arousal and awareness
Has sensation and cognition but complete paralysis except for vertical eye movements
What are some signs of trauma that you should look for during the examination of a coma patient?
- Racoon Eyes
- Battle’s Sign (bruising behind the ears)
- CSF leak (otorrhea, rhinorrhea)
What are essential elements of the neurological examination?
- pupillary responses
- corneal reflex
- extraocular movements
- cough/gag reflex
- motor responses
- respiratory pattern
What is anisocoria?
How do you determine the abnormality?
unequal size of pupils
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
If the pupil is enlarged on one side, what should you consider?
Parasympathetic Dysfunction (usually CN III lesion)
If the pupils are enlarged bilaterally, what should you consider?
Bilateral CN III lesion, post-ictal (after a seizure), intoxications
If the pupils are constricted, what should you consider?
Sympathetic dysfunction
If the pupils are pinpoint, what must be considered?
Pontine lesion, opiates, pilocarpine
If a patient is taking atropine/scopolamine, how may the interpretation of pupillary signs be affected?
Dilated, fixed
A patient presenting with anoxia may present with what type of pupillary response?
Possibly dilated, fixed, unequal
Dysconjugate roving eye movements imply what?
Brainstem Lesion
A bobbing nystagmus indicated a lesion in what region of the brain?
Pons
What is the Oculocephalic Maneuver, and what is used to assess?
It is the reflex that causes your eyes to move when rotating your head. Also known as “Doll’s Eyes”
Used to assess cranial nerves III, IV, and VI
Define a Cheynes - Stokes respiratory pattern
Hyperpnea (increased rate of breathing) regularly alternating with apnea
What is apneustic breathing?
What kind of lesion does this indicate?
Long inspiration, followed by apnea
Mid/Low pontine lesion
What are the effects of an uncal transtentorial herniation?
Herniation of the uncus under the edge of the tentorium:
- compressing CN III (ipsilateral dilated pupil, poor EOM, ptosis)
- then contralateral brainstem (ipsilateral hemiparesis)
- then respiratory abnormalities, posturing, fixed pupils, and death
If there is a hematoma, what are some signs that may present first?
- confusion and stupor commonly precede motor signs
- Motor signs are usually symmetrical
- Asterixis, myoclonus, tremor, seizures are common
- Level of consciousness may fluctuate
Is brain death reversible?
nah fam
What is the time criteria for brain death?
6 hours with a flat EEG
12 hours without a flat EEG
24 hours for anoxic brain injury without flat EEG
