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Neuro Exam 2 > Coma and PVS > Flashcards

Coma and PVS Flashcards

1
Q

coma

A

*severely depressed responsiveness
*defined by Glasgow Coma Scale

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2
Q

acute encephalopathy

A

*rapidly developing pathobiological process in brain
*within hours, days, less than 4 weeks

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3
Q

delirium

A

*clinical state characterized by combination of features (DSM-V)
*disturbance in awareness, attention, and cognition, short period, acute change, fluctuates, not explained by neurological disorder, direct consequence of medical condition

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4
Q

brain lesions that cause coma

A

*diffuse cortical damage; global anoxia
*diencephalon injury; tumor
*caudal diencephalon and upper midbrain paramedian basial stroke
*brainstem lesions involving ARAS

note - brainstem lesions may be very large without causing coma if they don’t involve the ARAS bilaterally

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5
Q

ascending arousal system

A

*cholinergic system - INPUT into the reticular nucleus, thalamus, and upper brainstem
*cortical activation (glutamate, norepinephrine, etc)

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6
Q

NREM sleep vs coma

A

*BOTH have EEG patterns (increased high voltage slow waves) and both have lack of activity of ascending arousal system
*sleep = intrinsically regulated inhibition of arousal system
*coma = impairment of the arousal system by damage, diffuse dysfunction of its diencephalon/forebrain targets

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7
Q

approach to patient with coma

A
  1. evaluate/treat circulation, airway, breathing, and cervical spine
  2. exclude/treat hypoglycemia or opioid/benzodiazepine overdose
  3. serum chemistries, arterial blood gas, urine toxicology screen
  4. emergent cranial CT (CT angio brain if appropriate) to determine if coma etiology is structural or vascular
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8
Q

“house” approach for etiology of coma

A

1) structural
2) vascular
3) electric
4) chemisty/metabolic

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9
Q

examples structural etiologies of coma

A

-subdural hygroma causing midline shift and falcine herniation
-left MCA ischemic stroke, causing malignant cerebral edema and uncal herniation
-right basal ganglia hemorrhage with intraventricular hemorrhage
-obstructive hydrocephalus causing bilateral midbrain compression

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10
Q

example vascular etiologies of coma

A

-brainstem infarcts caused by acute basilar artery thrombus

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11
Q

metabolic causes of coma/altered mental status

A

*hypoglycemia
*hypoxemia
*toxin accumulation
*neurotransmitter deficiency or surplus

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12
Q

diagnostic evaluation of altered mental status

A

*history
*physical exam
*labs
*imaging

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13
Q

important history for altered mental status

A

*onset
*recent symptoms
*injury
*known medical illness (ex a-fib)
*psych history
*access to drugs (therapeutic or recreational)

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14
Q

important physical exam for altered mental status

A

*ABC (airway, breathing, circulation)
*vitals - BP, HR, RR, respiratory patterns, O2 sats
*systemic exam (nuchal rigidity, trauma, ingestion/njection/illness)
*neuro exam:
-mental status: GCS, arousal, awareness
-brainstem reflexes (pupil eye mvmts, corneal, oculovestibular, oculocephalic, cough/gag)
-muscle (motor response, reflexes, tone)
-sensory/cerebellar !!
-fundoscopy

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15
Q

Cheynes-Stokes respiratory pattern in coma patient

A

*characterized by cyclical episodes of apnea and hyperventilation
*INTACT brainstem respiratory reflexes

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16
Q

hyperventilation respiratory pattern in coma patient

A

indicative of:
-bihemispheric lesions
-midbrain
-pons

17
Q

apneic respiratory pattern in coma patient

A

indicative of:
-bilateral pons
-severe metabolic derangement

18
Q

pupil reflexes in acute uncal herniation

A

*3rd nerve palsy (dilated pupil, down and out)

19
Q

3 P’s of acute lesions to PONS

A

*paralysis
*pinpoint pupils
*pyrexia (fever)

20
Q

glasgow coma scale

A

*a numerical scale of 15 that determines a patient’s level of consciousness based on eye opening, verbal response, and motor response
*scored based on best response (not for each limb)
*GCS 8… intubate

21
Q

GCS - eye opening scale

A

4 = spontaneously
3 = to speech
2 = to pain
1 = no response

22
Q

GCS - verbal response scale

A

5 = oriented to time, person, and place
4 = confused
3 = inappropriate words
2 = incomprehensible
1 = no response

23
Q

GCS - motor response scale

A

6 = obeys command
5 = moves to localized pain (actively shoving pain away)
4 = flex to withdraw from pain
3 = abnormal flexion (decorticate posturing)
2 = abnormal extension (decerebrate posturing)
1 = no response

24
Q

brainstem deficits and limb weakness on same side indicates

A

cortical/subcortical damage

25
Q

brainstem deficits and limb weakness on opposite sides of the body indicates

A

brainstem damage

26
Q

falcine herniation - syndrome

A

contralateral leg weakness (if ACA gets compressed)

27
Q

uncal herniation - syndrome

A

*sluggish then blown pupil
*parasympathetic fibers of CN3
*down and out eyeball with ipsilateral ptosis
*contralateral paralysis
*PCA infarction

**Kernohan’s notch on autopsy

28
Q

transtentorial herniation - syndrome

A

diencephalic > mesencephalic > medullary stage

29
Q

management of coma

A

*ABCs
*thiamine, glucose, narcan
*emergent neuroimaging
*evaluate for acute stroke
*evaluate for acute seizures
*early differential diagnosis drives early evaluation: structural/nonstructural/metabolic

30
Q

coma: awareness and arousal states

A

*no arousal
*no awareness

31
Q

vegetative state: awareness and arousal states

A

*full arousal
*no awareness

32
Q

minimally conscious state: awareness and arousal states

A

*full arousal
*partial awareness

33
Q

locked-in syndrome: awareness and arousal states

A

*full arousal
*full awareness
*NO VOLUNTARY MOVEMENT

34
Q

persistent vegetative state

A

*unawareness unwakefulness syndrome
*a person is AWAKE but is showing NO SIGNS of awareness (opens eyes, wake up and fall asleep at regular intervals, have basic reflexes)
*no meaningful responses, such as following an object with their eyes or responding to voice

35
Q

minimally conscious state

A

*person shows clear but minimal or inconsistent awareness
*periods where they can communicate or respond to commands

36
Q

locked-in syndome

A

*person is both conscious and aware, but completely paralyzed and unable to speak
*able to move their eyes, sometimes able to communicate by blinking
*REVERSIBLE if caught in time
*causes: basilar stroke, central pontine myelinolysis, or pontine hemorrhage

37
Q

akinetic mutism

A

*abulia (lack of will, drive, or initiative for action, speech, and thought)
*akinesia
*no cognitive function = no motivation
*intact sleep-wake cycle and NO MOTOR, SENSORY, or SPEECH DEFICITS
*bilateral basal medial frontal lobe

38
Q

brain death

A

*NO evidence of BRAIN function
*NO evidence of BRAINSTEM function
*NO evidence of spontaneous breathing
*underlying irreversible brain injury

Neuro Exam 2 (24 decks)

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