Disorders of Consciousness

Question 1

Altered Mental Status (AMS): _____

Answer 1

A change in mental function that stems
from illness, disorders, and injuries affecting the brain that can result in
changes in awareness, movement, and behaviors.

Question 2

There are three main types of AMS

Answer 2

● Delirium: Sudden and reversible, usually due to a medical emergency
such as injury or metabolic derangement (
the main discussion today).
● Dementia: Progressive decline in mental functioning that affects daily
life, primarily seen in geriatric patients.
● Psychosis: Temporary condition in which a person loses touch with
reality, usually due to a mental health condition or medication.

Question 3

_____: A chiefly mental condition marked by absence of spontaneous movement, greatly diminished responsiveness to stimulation, and
usually impaired consciousness

Answer 3

Stupor

Question 4

Coma: _____

Answer 4

A state of profound unconsciousness caused by disease, injury, or
poison. A patient experiencing coma could be described as comatose

Question 5

Syncope: _____

Answer 5

Loss of consciousness resulting from insufficient blood flow to the brain. Syncope is generally neurologic or cardiovascular in nature

Question 6

When a patient with Altered Mental Status presents to the clinic or ED,
this should immediately trigger an ____

Answer 6

urgent evaluation and workup

Question 7

The top 3 causes of delirium and coma
outside the hospital:

Answer 7

○ Intoxication (ETOH or drugs)
○ Diabetic Dysregulation
○ Traumatic Brain Injury (TBI)

Question 8

In general, the initial management priority
in any cause of unresponsiveness is to
_____

Answer 8

protect the patient’s airway and breathing
○ Most patients who are in a comatose
state require intubation

Question 9

In an emergent situation (usually in the ED), the approach to a patient
with altered mental status is the following:

Answer 9

○ Stabilize
○ Diagnose
○ Manage

Question 10

Classification and Causes of Coma - Structural brain injury

Answer 10

○ Intracerebral Hemorrhage
○ Aneurysmal Subarachnoid Hemorrhage
○ MCA Occlusion
○ Hemorrhagic Contusion
○ Cerebral Abscess
○ Brain Tumor
○ Penetrating TBI
○ Closed TBI
○ Anoxic/Ischemic Encephalopathy
○ Multiple Cerebral Infarcts

And others

Question 11

Classification and Causes of Coma - brainstem

Answer 11

○ Pontine Hemorrhage
○ Basilar Artery Occlusion
○ Central Pontine Myelinolysis
○ Brainstem Hemorrhagic Contusion

Question 12

Classification and Causes of Coma - cerebellum

Answer 12

○ Cerebellar Infarct
○ Cerebellar Hematoma
○ Cerebellar Abscess
○ Cerebellar Tumor

Question 13

Classification and Causes of Coma - Acute Metabolic/Endocrine Derangement

Answer 13

○ Hypoglycemia
○ Hyperglycemia
○ Hyponatremia
○ Hypernatremia
○ Addison’s Disease
○ Hypercalcemia
○ Acute Hypothyroidism
○ Acute Panhypopituitarism
○ Acute Uremia
○ Hyperbilirubinemia
○ Hypercapnia

Question 14

Classification and Causes of Coma - Diffuse Physiological Brain Dysfunction

Answer 14

○ Generalized Seizures
○ Poisoning/Toxicity
○ Illicit Drug Use
○ Hypothermia
○ Gas Inhalation
○ Acute Malignant Neuroleptic Syndrome

Question 15

Classification and Causes of Coma - Psychogenic Unresponsivenes

Answer 15

○ Hysterical
○ Malingering or Factitious
○ Conversion Disorder

Question 16

Assessment of the vital signs may reveal Cushing’s Triad, which is:

Answer 16

○ This important triad refers to a set of signs that are indicative of
increased intracranial pressure (ICP), and consists of:
■ Bradycardia
■ Irregular breathing (Cheyne-Stokes Respirations)
■ Widened pulse pressure

Question 17

If ICP increases, MAP should increase to maintain CCP. If CCP falls too much, the
brain can become _____

Answer 17

hypoxic

Question 18

The presence of _____ is considered a poor prognostic indicator

Answer 18

Cushing’s Triad

Question 19

____ is when the patient can clearly obey commands for movement

Answer 19

M6

Question 20

____ is when the patient does not clearly follow commands, but when
presented with a noxious stimulus, they localize to the pain

Answer 20

M5

Question 21

____ is when the patient does not
localize, but does withdraw from
noxious/painful stimuli

Answer 21

M4

Question 22

_____ are when the patient
responds to painful stimuli by
abnormal posturing

Answer 22

M3 and M2

Question 23

____ is when there is no motor response

Answer 23

M1

Question 24

_____ are both common means of administering noxious or painful stimuli, but may also result in a reflex that is mostly spinal in nature

Answer 24

Pinching nail beds and the sternal rub

Question 25

One way of administering a painful stimulus that does not pass through the spinal cord is by _____

Answer 25

pressing firmly on the Supraoptic Nerve, which is a distal branch of the Trigeminal Nerve (V1)

Question 25

What does abnormal posturing mean?

Answer 25

an involuntary motor response that is highly indicative of severe brain/brainstem injury (with very poor prognosis)

Question 25

The _____ in the midbrain helps to coordinate motor function in the extremities, along with the Basal Ganglia and Cerebellum

Answer 25

Red Nucleus

Question 26

_____ occurs when the connections to the Red Nucleus are severed or damaged

Answer 26

Abnormal posturing

Question 27

Decorticate Posturing

Answer 27

Also known as Flexor Posturing, results from damage to the red nucleus associated motor pathways above the red nucleus.

Question 28

Decerebrate Posturing

Answer 28

also known as Extensor Posturing, results from damage to the red nucleus associated motor pathways below the red nucleus in the brainstem

Question 29

T/F a cranial nerve assessment can mostly still be completed even in AMS

Answer 29

T

Question 30

_____ can be related to opioid overdose, but can also be a sign of a pontine hemorrhage that interrupts sympathetic outflow to the pupils

Answer 30

Pinpoint pupils

Question 31

A dilated pupil (which may be unresponsive or “blown”) in a comatose patient can indicate ______

Answer 31

brainstem injury or increased intracranial pressure.

Question 32

Medication that can dilate pupils

Answer 32

Amphetamines

Question 33

Tonic deviation of the eyes in a horizontal plane may indicate an _____ affecting the frontal eye fields (such as hemorrhagic stroke in the frontal lobe).

Answer 33

ipsilateral hemispheric lesion

Question 34

What is dolls eyes?

Answer 34

○ Normally rotating the head side to side causes the eyes to shift so the gaze is maintained, but in severe brainstem injury or brain death, the eyes do not shift with head rotation

Question 35

Imaging of choice for patients that have AMS

Answer 35

noncontrast Head CT

Question 36

Lab testing for AMS

Answer 36

○ POC Glucose ○ CMP ○ CBC ○ PT/INR ○ PTT ● ABGs should be drawn as soon as possible. ● Consider Troponins if there is a cardiac concern. ● Consider an LP if a neuro infection is suspected

Question 37

Syncope presentation

Answer 37

● Syncope should be thought of as a symptom more than a diagnosis, and is a transient, brief, and self-limited loss of consciousness. ○ Syncopal episodes are followed by prompt recovery without resuscitative measures

Question 38

Reflex Syncope

Answer 38

(neural mediated) is generally due to excessive vagal tone or impaired reflex of peripheral circulation. ■ The most common type is Vasovagal Syncope, often initiated by a stressful, painful, or claustrophobic experience. ■ Enhanced vagal tone with resulting hypotension, cerebral hypoperfusion.

Question 39

Orthostatic (postural) Hypotension

Answer 39

another common cause of syncope in which normal vasoconstrictive response to assuming an upright posture is impaired. ■ Common in older adults, or patients with diabetic neuropathy, POTS, hypovolemia, or patients taking vasodilators, diuretics, or beta-blockers.

Question 40

Cardiogenic Syncope

Answer 40

generally either mechanical or arrhythmic, and generally occurs rather suddenly without warning (injury risk is high). ■ Mechanical is generally valvular in nature, as can occur with aortic stenosis (where the heart cannot increase stroke volume in circumstances of increased peripheral demand), pulmonary stenosis, HOCM, etc.

Question 41

More commonly, cardiogenic syncope occurs due to a _____

Answer 41

sudden arrhythmia event

Question 42

Vasovagal syncope generally has a prodrome of symptoms (sometimes called vasodepressor premonitory symptoms), which can include _____

Answer 42

nausea, diaphoresis, tachycardia, and pallor

Question 43

T/F Cardiogenic syncope has a prodrome of symptoms

Answer 43

F

Question 44

All patients presenting with syncope should get a ______

Answer 44

12-lead EKG

Question 45

Treatment and Referral Considerations for syncope

Answer 45

○ In cases of vasovagal syncope (most common), treatment generally consists of patient education on the benign nature of the condition and about avoiding predisposing situations ○ For patients experiencing recurrent vasovagal syncope, counterpressure maneuvers (squatting, leg crossing, abdominal contraction) can sometimes be helpful for terminating episodes ○ If symptomatic bradyarrhythmias or supraventricular tachycardias are detected and felt to be the cause of cardiogenic syncope, permanent pacing (implanted defib/pacemaker) is indicated

Question 46

_____ is an alpha-agonist that can increase peripheral vasoconstriction and has been shown to reduce the frequency of syncopal episodes in small trials

Answer 46

Midodrine