PD Neuro Part 1 Flashcards
1
Q
Concerning neuro symptoms
A
Changes in mood, attention, or speech Changes in memory, orientation, insight, or judgement Delirium or dementia Headache Pain Dizziness or vertigo Weakness Numbness/loss of sensation Syncope Seizures Tremors or involuntary movement
2
Q
Areas of neuro exam
A
Mental status Cranial nerves Motor system Sensory system Reflexes
3
Q
Mental status exam
A
Total expression of a person’s emotional responses, mood, cognitive functioning, and personality
Determined throughout interview
4
Q
Mental status exam appearance and behavior
A
Grooming
Emotional status
Body language
5
Q
Mental status exam emotional stability
A
Mood and feelings
Thought processes
6
Q
Mental status exam cognitive abilities
A
State of consciousness
Memory
Attention span
Judgement
7
Q
Mental status exam speech and language
A
Voice quality Articulation Comprehension Coherence Aphasia
8
Q
Prep for mental status exam
A
Make patient comfortable and secure
Make it easy for patient to talk freely
Trust, confidentiality, desire to help
9
Q
Difficult to separate … from … history
A
Separate medical from psychiatric history
10
Q
History for MSE
A
ETOH use Drug abuse Recent medications Suicidal thoughts/attempts Homicidal/unusual behavior History of mental illness
Previous hospitalizations Prior visits to practitioners Family history Birth and developmental hx School record Work experience Antisocial behavior/legal problems Marital hx Interpersonal relationships Home life Military hx
11
Q
Describing speech
A
Soft Loud Stuttering Hesitancy Accent Enunciation Rate Relationship to motor activity Delay Coherency Disorganized speech
12
Q
Delusion
A
Abnormalities in the content of thought
False beliefs which cannot be explained, including by patient’s cultural background
13
Q
Types of delusion
A
Persecutory Jealousy Sin or guilt Gradiose Religious Somatic Reference Being controlled Mind reading Thought broadcast Thought insertion Thought withdrawal
14
Q
Hallucinations
A
Abnormalities in perception, which occur in the absence of some identifiable external stimulus
15
Q
What sensory modality are affected by hallucinations?
A
All: Hearing Sight Smell Taste Touch
16
Q
What must a patient describe about hallucinations?
A
Must describe an actual, specific perception
17
Q
Questions for suicidal homicidal ideation
A
Very important to remember these questions in all psychiatric examinations
Ask directly about thoughts of self harm or harming others
Do you have a plan?
18
Q
Risk factors for suicide
A
Hx of mental DO ETOH or drug abuse Major physical illness Job loss Relationship loss Lack of support system Impulsive behavior
19
Q
Activities of daily living dependent on…
A
Patient’s mental status
20
Q
Basic ADLs
A
Bathing Dressing Toileting Feeding Ambulating
21
Q
Instrumental ADLs
A
Housekeeping Grocery shopping Meal preparation Managing medications Communication skills Money management
22
Q
Glasgow Coma Scale
A
Used to quantify consciousness when a patient has altered level due to head trauma or hypoxic event
Developed to predict mortality and for emergency assessment of consciousness
23
Q
What two brain components do we assess with a GCS?
A
Cerebral cortex and brainstem
24
Q
3 factors of GCS
A
Eye opening - 4 points
Verbal response - 5 points
Motor response - 6 points
25
Max and min GCS
3-15
26
Eye opening
4 - spontaneously
3 - speech
2 - pain
1 - none
27
Verbal response
```
5 - orientated
4 - confused
3 - inappropriate
2 - incomprehensible
1 - none
```
28
Motor response
```
6 - obeys commands
5 - localizes pain
4 - withdraws from pain
3 - flexion to pain
2 - extension to pain
1 - none
```
29
Unexpected levels of consciousness
```
Confusion
Lethargy
Delirium
Stupor
Coma
```
30
Confusion
Inappropriate responses to questions
Decreased attention span
Decreased memory
31
Lethargy
Drowsy, falls asleep easily
| When aroused, responds appropriately
32
Delirium
Confusion accompanied by agitation or hallucinations
Inappropriate reactions to stimuli
Confusional state characterized by disturbance of consciousness, impaired attention, and change in cognition
33
Stupor
Arousable for short periods by questions or painful stimuli
34
Coma
Motionless
| Unresponsive to stimuli
35
Mini mental state exam
Standardized method for grading the cognitive state of patients
36
Max score for mini exam
30
37
Depressed patients without dementia score for mini exam
24-30
38
Score of 20 or less on mini exam
Dementia
Delirium
Schizophrenia
Affective disorder
39
Components of mini mental status exam
Orientation: season, D/M/Y, day, city, state, hospital
Registration - name 3 objects, have pt repeat
Attention/calculation - serial 7s
Recall - repeat 3 objects
Language - pt says "no ifs, ands, or buts about it"
Pt follows 3 step command
40
Dementia
Syndrome of failing memory and impairment of other intellectual functions, behavioral abnormalities, and personality changes
Chronic progressive deterioration of the brain
Usually related to obvious structural diseases of the brain tissue
Most causes non-reversible
41
Dementia symptoms
Insidious onset
Cognitive impairment - permanent and progressive
Agnosia
Speech/language -disordered, rambling, incoherent, struggles to find words
Mood and affect - depressed, apathetic, uninterested
Delusions
NO hallucinations
42
Agnosia
Loss of ability to recognize persons, objects, etc
43
Types of dementia
```
Alzheimer's
Vascular dementia - multi-infarct dementia
Lewy body dementia
Alcohol induced
Parkinson's
```
44
Delirium
Confusional state characterized by disturbance of consciousness, impaired attention, and change in cognition
Confusion accompanied by agitation or hallucinations
Inappropriate reactions to stimuli
45
Etiology of delirium
```
Hypoxia or hypercapnea
Sepsis
Uremia
Electrolyte imbalance
ETOH withdrawal
Meds
Brain injury
Liver failure
```
46
Is delirium curable?
Yes - reversible if treating underlying problem
47
Delirium symptoms
```
Acute onset
Duration - hours to days
Anxiety, intense
Decreased memory
Decreased attentiveness
Decreased consciousness
Delusions/hallucinations - visual, auditory, tactile
Mood/affect - rapid mood swings, fearful, suspicious, agitated
Disturbed sleep
```
48
Depression
Common psych illness
Symptoms range from mild to psychotic
Episodic or persistent
49
Causes of depression
Grief
| Reaction to medical DO
50
Symptoms of depression
Mood and affect - extreme sadness, anxious, irritability
Somatic c/o - decreased appetite, HA, constipation, fatigue
Speech - slow/sluggish, slow to respond
Cognitive - c/o memory loss, inability to concentrate
51
CNS
Brain and spinal cord
| Main network of coordination and control of body
52
PNS
Carries info to and from the CNS
Motor and sensory nerves
Ganglia
53
How is the CNS protected?
Skull
Vertebrae
Meninges
CSF
54
3 layers of meninges
| Produce and drain...
Dura mater
Arachnoid mater
Pia mater
Produce and drain CSF
55
Where does CSF circulate?
Between an interconnecting system of ventricles in the brain and around the brain/spinal cord
56
Arteries to brain
2 internal carotid
2 vertebral
1 basilar
57
Veins draining brain
Venous sinuses that empty into the internal jugular veins
58
4 major regions of brain
Cerebrum
Cerebellum
Brainstem
Diencephalon
59
Brainstem
Medulla oblongata
Pons
Midbrain
60
Diencephalaon
Thalamus
Hypothalamus
Pituitary
61
Brain tissue colors
Gray or white
62
Gray matter
Made up of neuronal cell bodies
| Rims surface of cerebral hemispheres forming cerebral cortex
63
Deep clusters of gray matter
Basal ganglia
Thalamus
Hypothalamus
64
White matter
Consists of neuronal axons coated with myelin, allows nerve impulses to travel faster
65
Lobes of cerebrum
2 hemispheres each divides into 4 lobes
66
Frontal lobe
Motor cortex - voluntary mvmt
Speech formation
Areas for emotions, affect, drive, self-awareness
Autonomic response related to emotional stress
67
Frontal lobe area for speech
Broca's area
68
Parietal lobe
Processes sensory data
Interpretation of tactile sensations - pain, temp, texture
Visual, gustatory, olfactory, auditory sensation
Comprehension of written words, proprioception, recognition of body parts
69
Occipital lobe
Primary vision center and interpretation of visual data
70
Temporal lobe
Responsible for perception and interpretation of sounds
Speech area - comprehension of spoken word and written language
Integration of taste, smell, and balance, as well as behavior, emotion, and personality
71
Temporal lobe area for speech comprehension
Wernicke's
72
Cerebellum
Aids the motor cortex of cerebrum in the integration of voluntary movement
Processes sensory info from eyes, ears, touch receptors, musculoskeleton
Utilizes sensory data to control muscle tone, equilibrium, and posture
73
Brainstem
Pathway between cerebral cortex and spinal cord
| Control involuntary functions
74
Components of brainstem
Medulla oblongata
Pons
Midbrain
Diencephalon
75
What structures arise from brainstem?
Nuclei of the 12 cranial nerves arise from these structures
76
Cranial nerves
Peripheral nerves that arise from brain instead of spinal cord
Motor and/or sensory function
77
4 CN with parasympathetic functions
III, VII, IX, X
78
Basal ganglia
Pathway and processing station between motor cortex and upper brainstem
79
Autonomic nervous system
Regulates internal environment of body
Person has no voluntary control
2 divisions - balance the impulses of the other
80
Sympathetic nervous system
Prods body into action during time of physiologic and psychologic stress
81
Parasympathetic nervous system
Conserves body resources and maintain day-to-day body functions (digestion and elimination)
82
Spinal cord
Extends from medulla to L1-L2
Conus medullaris
Cauda equina
Sensory, motor, autonomic impulses between brain and body
83
Level of cauda equina
L4
84
White matter tracts of SC
Ascending and descending tracts
85
Gray matter of SC
Butterfly shape with anterior and posterior horns
86
Descending spinal tracts originate in...
Brain
87
Pyramidal tract
Great motor pathway that carries impulses for voluntary movement
88
Ascending spinal tracts
Mediate various sensations
89
Posterior dorsal column
Carry fibers for discriminatory sensations of touch, deep pressure, vibration, position of joints, stereognosis, +2 point discrimination
90
Spinothalamic tracts
Carry fibers for crude touch, pressure, temp, and pain
91
... Motor neurons make up the descending pathways from brain to spinal cord
Upper motor neurons
92
Lower motor neurons originate... and terminate...
Originate in anterior horn
| Terminate in muscle fibers
93
How many pairs of spinal nerves?
```
31 pairs
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
```
94
Spinal nerves arise... and exit...
Arise from SC and exit at each intervertebral foramen
95
Dermatome
Sensory and motor fibers of each spinal nerve supply and receive information in a specific body distribution
96
Formation of nerve plexus
Anterior branches of several spinal nerves combine
97
Spinal nerve separates into...
Ventral and dorsal roots
98
Ventral root
Motor fibers carry impulses from SC to the muscles and glands of the body
99
Dorsal root
Sensory fibers carry impulses from the sensory receptors of the body to the SC
100
Impulses from dorsal root travel...
Up to brain for interpretation
| Initiate reflex action when it synapses immediately with motor fiber after a stimulus
101
Reflex arc
Dependent upon intact afferent nerve fibers, functional synapses in SC, intact motor nerve fibers, functional NMJ, and competent muscle fibers
102
When upper motor neurons are damaged above the cross over of its tracts in the medulla, motor impairment develops on what side?
Contralateral
103
In damage below the cross over, motor impairment occurs on what side?
Ipsilateral
104
How many pairs of peripheral nerves?
12 pairs
105
Where do peripheral nerves arise from?
Brainstem/diencephalon
106
```
Where do these nerves arise from?
I-II
III-IV
V-VIII
IX-XII
```
I-II diencephalon
III-IV midbrain
V-VIII pons
IX-XII medulla
107
Motor and sensory innervation of the head and neck
Voluntary muscles
Visceral motor
General sensation
Special sensation
108
Name cranial nerves
```
I Olfactory
II Optic
III Oculomotor
IV Trochlear
V Trigeminal
VI Abducens
VII Facial
VIII Vestibulococchlear
IX Glossopharyngeal
X Vagus
XI Spinal accessory
XII Hypoglossal
```
109
Which senses are not routinely tested?
Taste and smell are not routinely tested unless abnormality suspected
110
Prep for sensory testing
Patients eyes are closed
111
Sensory testing
Light touch
| Sharp versus dull
112
Light touch
Light strokes of cotton swab or brush/monofilament
| Ask for when and where stimulus was felt
113
Sharp versus dull
Tests superficial pain
Broken tongue blade, paper clip
Alternate sharp and dull testing in unpredictable fashion
Ask pt if they feel sharp versus dull and location
114
CN I
```
Special sense of olfaction
Anosmia
Patient closes eyes
Make sure both nares are patent
Occlude one nostril and test smell with familiar, non offensive odor
Test opposite using different odor
```
115
Causes of anosmia
```
Nasal disease
Allergies
Trauma
Smoking
Aging
```
116
CN I skull fracture
Tearing of fibers crossing cribiform plate
| CSF rhinorrhea
117
How to distinguish between rhinorrhea and CSF
CSF is salty
118
CN I Frontal lobe mass
Tumors or abscess
| Leads to compression
119
CN I damage to primary cortical olfactory area
Temporal lobe
| Masses or seizures may present with olfactory hallucinations
120
CN II motor or sensory
Sensory
121
CN II
Visual acuity and visual field testing portion of eye exam
| Fundoscopic exam for direct visualization
122
CN III motor or sensory
Motor
123
CN III
Raise eyelids
Extraoccular movements
Parasympathetic - pupillary constriction, changes in lens shape
124
CN IV motor or sensory
Motor
125
CN IV
Downward, inward eye movement
| Extraocular movements
126
CN V motor or sensory
Motor and sensory
127
CN V motor
Jaw opening/clenching
Chewing
Mastication
128
CN V sensory
```
Cornea
Iris
Lacrimal glands
conjunctivae
Eyelids
Forehead
Nose
Nasal and oral mucosa
Teeth
Tongue
Ear
Face
Scalp
```
129
Divisions of trigeminal
| Sensory or motor
V1 - opthalmic (sensory)
V2 - maxillary (sensory)
V3 - mandibular (both)
130
Testing CN V motor
Observe face for muscle atrophy, jaw deviation, fasciculations
Have pt clench teeth as you palpate masseter and temporalis is muscles
131
What condition are you suspicious of with fasiculations?
ALS
132
Testing CN V sensory
Test each division (All 6) for light touch, sharp versus dull
Test corneal reflex
133
What would we test if normal CN V sensory function is impaired?
If impaired, test temp sensation using test tubes filled with hot or cold water in all 6 divisions and compare
134
Who do we test corneal reflex in?
Comatose patients
135
What is the normal response for corneal reflex?
Blink when cotton wisp touches cornea
136
What two CN need to be intact for the corneal response?
CN V and VII
137
Which branch of trigeminal is dangerous to be infected with herpes zoster?
V1 - risk of blindness
| Opthalmic emergency!
138
Trigeminal neuralgia
Unilateral pain syndrome, usually limed to 1 division of Cn V
Hot lancinating pain can be debilitating
Ofte associated with trigger - light touch, chewing, sneezing
139
Cause of tic douloureux
Idiopathic
140
Most common patient with CN V neuralgia
Over 60
141
Neuro exam with tic douloureux
Unrevealing
142
Treatment for trigeminal neuralgia
```
Carbamazepine (Tegretol)
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Microvascular decompression
Gamma Knife
```
143
CN VI motor or sensory
Motor
144
CN VI
Lateral eye movement
145
CN VII motor or sensory
Motor and sensory, parasympathetic
146
CN VII motor
Movement of facial expression muscles except jaw
Close eyes
Labial speech sounds (b, m, w, p)
147
CN VII sensory
Taste on anterior 2/3 of tongue (salty/sweet)
Taste on posterior 1/3 tongue (bitter)
Sensation to pharynx, auricle, and small area skin posterior
148
Anterior tongue
Anterior 2/3 salty/sweet
149
Posterior tongue
Posterior 1/3 bitter
150
Parasympathetic CN VII
Secretion of saliva and tears
151
CN VII testing facial function
```
Motor function assessed by facial functions:
Raise eyebrows
Squeeze eyes shut as tightly as possible and against resistance
Wrinkle forehead
Smile
Show teeth
Frown
Purse lips
Puff cheeks
Listen to speech
```
152
CN VII taste testing
Not routinely done unless abnormality suspected
Four solutions - salty, sweet, sour, bitter
Apply one at a time to area of tongue
153
What other CN are we testing when testing taste with CN VII
CN IX - taste to posterior 1/3 of tongue
154
Reflexes involving CN VII
Corneal V --> VII
Bright light II --> VII
Loud noise VIII --> VII
Suck reflex in infant V --> VII
155
CN VII Bell's palsy
```
Inability to wrinkle brow
Drooping eyelid
Inability to close eye
Inability to puff cheeks - no muscle tone
Drooping mouth
Inability to pucker or smile
```
156
CN VIII
Special sense
Auditory info from cochlea
Balance info from semicircular canal
157
Testing auditory CN VIII
Whisper test
Weber
Rinne
Audiometric evaluation
158
Testing vestibular CN VIII
Romberg test
159
Romberg test
Patient stands with feet tightly together, eyes closed, arms out in front
Observe for drifting, loss of balance
160
Positive Romberg test indicates...
Vestibular dysfunction
Cerebellar ataxia
Sensory loss
161
What do you need to make sure to do when doing the Romberg test?
Protect your patient!
162
CN IX motor or sensory
Motor, sensory, parasympathetic
163
CN IX motor
VOluntary muscles for swallowing and phonation
164
CN IX sensory
Sensation of nasopharynx
Gag reflex
Taste - posterior 1/3 of tongue
165
CN IX parasympathetic
Secretion of salivary glands
| Carotid body/sinus reflex
166
What nerve is simultaneously tested during examination, and for what sensations?
IX is simultaneously tested during exam of CN X for nasopharyngeal sensation (gag reflex) and motor function of swallowing
167
CN X motor or sensory
Motor and sensory, parasympathetic
168
CN X motor
Voluntary muscles of phonation and swallowing
169
Voluntary muscles of phonation
Guttural speech sounds - harsh sounds produced in throat/back of mouth
170
CN X sensory
Sensation behind ear and part of external auditory canal
171
CN X parasympathetic
Secretion of digestive enzymes
Peristalsis
Carotid reflex
Involuntary action of heart, lungs, and GI tract
172
Gag reflex CN
CN IX and X
173
Gag reflex
Evaluating nasopharyngeal sensation
Tell patient
Touch posterior wall of pharynx with tongue blade
Observe upward mvmt of palate and contraction of the pharyngeal muscles
Uvula should remain midline
No drooping or absence of arch on either side of soft palate should be noted
174
CN IX and X
Motor function is evaluated by again inspecting soft palate for symmetry
Have pt say aahh and observe for mvmt and asymmetry
Easily swallows water
Listen to speech
175
Damage of IX and X
Palate will fail to rise and uvula will deviate from midline
Retrograde passage of water through the nose
Hoarseness, nasal quality, difficulty with guttural sounds
176
CN XI motor or sensory
Motor
177
CN XI
SCM and trapezius innervation
178
Testing CN XI
Have pt shrug shoulders against resistance
179
CN XII motor or sensory
Motor
180
CN XII motor
Tongue movement for lingual speech articulation (l, t, n) and swallowing
Inspect tongue while at rest on floor of mouth and while protruding
Assess strength of tongue by having pt press tongue against inside of each cheek against resistance
181
Tongue deviation with CN XII lesion
Deviates towards lesion
182
Evaluation of proprioception and cerebellar function
Rapid rhythmic alternating movements
Accuracy of movements
Balance (equilibrium, gait)
183
Rapid rhythmic alternating movements
Ask seated patent to pat his hands on his knees with both hands, alternately turning palm up and down
Gradually increase rate
Pt touches thumb to each finger on same hand and increase speed
Movements should be smooth, maintaining rhythm
Looking for stiff, slowed, nonrhythmic, or jerky clonic movements
184
Accuracy of movement tests
Finger to finger test
Finger to nose test
Heel to shin test
185
Finger to finger test
Pt uses index finger to alternately touch his nose and your index finger
About 18 inches away
Moving around
186
Finger to nose test
With eyes closed have pt touch their own nose with their index finger, alternating hands
Increase speed
187
Heel to shin test
Sitting, standing, or supine
Pt runs the heel of one foot down the shin of the other leg
Heel should move straight up and down shin in straight line
188
Equilibrium test
Romberg test
189
If patient staggers or loses balance during Romberg test...
Defer further tests of cerebellar function requiring balance
190
Further test of balance
Push pts shoulder with enough force to throw him off balance
Should recover balance quickly
Pt closes eyes, arms straight at sides, have pt stand on one foot, then the other
Should balance in about 5 seconds
Have pt hop on one foot, then the other
Should maintain balance for 5 seconds or more
191
Gait test
Observe pt walk without shoes
First with eyes open
Then eyes closed
Heel to toe walk
Walk on heels
Walk on tip toes
192
What to note during gait examination
```
Simultaneous arm movement and posture
Shuffling
Widely placed feet
Toe walking
Foot flop
Leg lag
Scissoring
Staggering
Loss of arm swing
```
193
Pronator drift
```
Standing or sitting
Pt puts arms straight out in front, palms up and eyes closed
20-30 seconds
Tap arms briskly downward
Arms should return smoothly
```
194
What are we testing during pronator drift?
Muscle strength
coordination
Sense of position
195
Positive pronator drift
Pt with upper motor neuron disease
Will not maintain position
Arm will drift down and start to pronate
196
Patients with asterixis
Metabolic encephalopathy
Uremia
Severe pulmonary insufficiency
Cerebrovascular disease
197
Asterixis test
Pt extends both arms in front with hands cocked up and fingers spread (stop traffic)
Sudden, brief, nonrhythmic "flapping" of hands
198
Meningeal signs
Nuchal rigidity
Brudzinski sign
Kernig sign
199
Nuchal rigidity
Patient is supine
Try and flex neck
Should be done with ease and pain free
Pain or resistance to neck motion is positive nuchal rigidity
200
Brudzinski sign
Involuntary flexion of hips and knees when flexing the neck
201
Kernig sign
Flexing the leg at the knee and hip with patient supine
Attempt to straighten the leg
Pain in the lower back and resistance to straightening the leg
202
Abnormal posture in comatose patients
Decorticate rigidity
| Decerebrate rigidity
203
Decorticate rigidity
Abnormal flexor response
Upper arms are held tight to sides with elbows, wrists, and fingers flexed
Legs are extended and internally rotated
Feet plantar flexed
204
Cause of decorticate rigidity
```
Indicates damage to corticospinal tract above brainstem
Ex. IC hemorrhage
Head injury
Increase IC pressure
Stroke
```
205
Which is more favorable, decorticate or decerebrate?
Decorticate
206
Decerebrate rigidity
Abnormal extensor response
Jaws clenched, neck extended
Arms fully extended, forearm pronated, wrist/fingers flexed
Back may be arched
Feet plantar flexed
May occur spontaneously or only response to stimuli (nose, light, pain)
207
Causes of decerebrate rigidity
Indicates lesion in diencephalon, midbrain, or pons, although severe metabolic DOs (hypoxia, hypoglycemia) may also be the cause
208
Oculocephatlic reflex
| If brainstem is intact...
Doll's eyes
Make sure there is no neck injury
Hold open eyelids, then turn head quickly to one side, then to other side
If intact, as head turns to one side, the eyes move towards the opposite side
209
What does oculocephalic reflex assess?
Assesses brainstem function in stuporous or comatose patients
210
Does an alert patient have a oculocephalic reflex?
No, because the reflex is suppressed
211
Cause of lack of Doll's eyes
If reflex is absent, suggests lesion or disorder of midbrain or pons
212
Oculovestibular reflex
Make sure TM intact and external canal is clear
Pts head at 30 degrees
With large syringe, inject cold water into ear canal
Watch for deviation of eyes in horizontal plane
If brainstem is intact, eyes drift toward irrigated ear
213
Do we test the oculovestibular reflex on alert patients?
No
214
What does the oculovestibular reflex assess?
Further assesses brainstem function when oculocephalic reflex is absent
215
Cause of absent oculovestibular reflex
If absent, suggests lesion of pons, medulla, or less commonly CN III, IV, VI, or VIII
216
Determining death for most patients
Cardiac activity
Respiratory activity
Neurologic activity
217
Cardiac activity to determine death
Palpate for pulsations in carotids
Auscultate precordium for heart sounds
If in doubt, get EKG
218
Respiratory activity to determine death
Listen for breath sounds over lungs and mouth
| Can hold cold mirror over mouth to look for water vapor
219
Neurologic activity to determine death
Call to patient to test mentation
Retract eyelids - pupils fixed and dilated in death
Rote head from side to side for Doll's eyes
If absent, perform oculovestibular reflex
Sternal run or squeeze Achilles to test for deep pain perception
Lift and let limbs fall to test for muscle tone
Gag reflex
220
Apnea test
```
Pre-oxygenate
Baseline ABG for CO2 level
Disconnect ventilator (but do not take O2 away)
Administer oxygen
Observe respirations
Draw ABG in 8-10 minutes
```
221
Brain death criteria of apnea test
pCO2 of greater than 60, or increase of greater than 20 over normal baseline, with no respiratory effort supports a positive apnea test consistent with brain death
222
Brain death
Irreversible cessation of all brain activity
| Brain is not capable of maintaining life without advance life support
223
What structure death is equivalent to brain death?
Brainstem death is equivalent to brain death because brainstem is essential to maintain life
224
Does a patient have a heartbeat with brain death?
Yes, they could
225
What happens to patients in a coma?
Some recover
Some enter persistent vegetative state
Some become brain dead
