Stupor & Coma Flashcards Preview

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Flashcards in Stupor & Coma Deck (30):
1

Lethargy

sleepy but easily aroused

2

Hypersomnia

-excessively sleepy but normal cognition when awakened

3

Obtundation

mental blunting, dec. alertness

4

Stupor

eyes open only briefly after vigorous stimulation before returning to deep sleep
-cognition impaired

5

Coma

eyes remain closed after vigorous stimulation

6

Delirium

-disoriented, misperception of sensory stimuli, hallucinations
-vacillates b/w quite, sleepy periods & hyper-vigilance/agitation

7

Abulia

-awake but apathetic, no spontaneity
-with vigorous stimulation, cognitive function may be normal (bilateral frontal lobe disease, lobotomized)

8

Akinetic Mutism

-silent, alert-appearing immobility
-no mental activity with vigorous stimulation (disease of frontal lobes & hypothalamus)

9

Minimally Conscious State

-fragments of awareness

10

Vegetative State

-awake, no awareness or meaningful interaction with the environment

11

Consciousness

1. Arousal: sleep-wake cycles
-ascending arousal system of the rostral brainstem
-disease causes stupor & coma

2. Content: awareness of: oneself, environment
-Corrtical circuits - cognition, purposeful interaction with world
-Disease causes dementia

12

Cataplexy

-sudden involentary loss of muscle tone during emotional excitement

13

Primary Lesions that Cause Coma

1. extensive, acute bihemispheric disease
2. lesions of diencephalon (thalamus & hypothalamus)
3. Lesions of midbrain peri-aqueductal grey
4. Involvement of upper 1/3 of pontine tegmentum

14

Causes of Coma

1. Structural Cause: supratentorial mass lesions, acute obstructive hydrocephalus, infratentorilal mass lesion
2. Metabolic (non-structural): reversible injury (sedative overdose), irreversible injury (hypoxia in cardiac arrest)

**always rule out psychogenic coma

15

Oculomotor nerve is near the?

tentorium

16

Central Herniation

-Rostral-Caudal deterioration
-Diencephalon (thalamus & hypothalamus) to midbrain failure
-reduced consciousness
-small reactive pupils (1-3mm)
-decorticate postruing
-Cheyne-Stokes respirations
-Midbrain failure follows (fixed mid-postiion pupils, decerebration)

17

Infratentorial Lesions

1. Intrinsic brainstem lesions:
-top of basilar artery ischemic stroke
-pontine hemorrhage

2. Extrinsic lesions compress & distory the brainstem
-cerebellar hemorrhage
-cerebellar infarction
-cerebellar brian tumor

18

Primary Brainstem Lesions cause:

-Segmental cranial nerve deficits
-ascending (spinothalamic) tract dysfunction
-descending (corticospinal, central sympathetic) tract dysfunction
-early cerebellar signs

19

Pontine Hemorrhage Clinical Syndrome

-coma abrupt
-pupils are pinpoint
-decerebrate rigidity or flacid quadriplegia
-horizontal gaze paresis
-ocular bobbing

20

Metabolic Encephalopathy (toxic-metabolic coma)

-Non-cerebral disease may interfere w/metabolism of the cerebral cortex & rostral brainstem AAS
-Endogenous toxins in uremia & hepatic failure
-Exogenous toxins in drug overdose, poisons, & sepsis
-Hypoxia, hypoglycemia, hypo & hyper-osmolality
-Electrolyte & acid-base imbalances
-Metabolic insult to brain is global, diffuse, symmetric
-Neuro-exam is "non-focal"
-Head CT is neg.
-Pupils stay reactive even as other reflexes are lost
-Asterixes, multifocal myoclonus & tremor
-Stupor & coma are reversible with metabolic correction & ICU support

21

Causes of Metabolic Encephalopathy

-hypoxia, CO2 narosis, Hypoglycemia, Hyperglycemia, Hyperosmolar, Hyponatremia, Dehydration, Uremia, Liver failure, Hyperthermia, Hypotheria, Acidosis
-Drug intox, toxins, sepsis, Wernicke's, Post-ictal state, DIC, TTP, Sever anemia, Lupus

22

Coma: Immediate Management

-Stablilize vital signs (ABC's first): secure ariway, cardiac monitor, IV access & blood drawing
-Stabilize neck (trauma)
-Determine the circumstances in which coma occurred
-Rapidly examine patient
-Empirical D50, thiamine, naloxone (opiate OD)
-tasks performed simulaneously by ED team

23

Respiratory Patterns in Coma

-Cheyne Stokes respirations can be an early sign of herniation, both central & transtentorial

24

Noxious stimuli to arouse patients who do not respond to voice command?

-supraorbital pressure
-nailbed pinch
-sternal rub

25

Glasgow coma scale

-prognosis in head trauma
-highest 15
12 or better is excellent prognosis
-scores of 7 or below: nursing home care
-3 means death

26

Flexor response to Pain

(decorticate posturing)
-due to loss of cortical control of brainstem

27

Extensor response

(decerebrate posturing)
-arises with loss of red nucleus & rubrospinal tract in the midbrain

28

Coma: Diagnostic Testing

-STAT Head CT (or MRI if available)
-CXR
-Tests: EEG (status epilepticus, brain death)
Spinal tap (CNS infection, subarachnoid hemorrhage)
Cervical Spine X-ray (trauma)
Stat toxicology: cocaine, opiates, phencyclidine, barbiturates, anticonvulsants, & sedatives, ethanol, methanol, ethylene glycol, acetaminophen, salixylates, tricyclics

29

Treatment of Coma

-Ensure Oxgenation
-Maintain circulation
-Control glucose
-Lower Intracranial pressure
-Stop Seizures
-Treat Infection
-Restore acid-base balance & electrolytes
-Adjust body temperature
-Give thiamine
-Consider specific antidotes (naloxone, flumazenil)
-Control agitation

30

Coma Prognosis

-Non-traumatic coma: absence of pupillary light & comeal reflex of 3 days carries poor prognosis

-In hypoxic coma, absence of purposeful motor movements at 3 days also carries a poor prognosis