NS2 Test 3 > Stupor and Coma > Flashcards

Stupor and Coma Flashcards

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1
Q

What is consciousness? Requirements?

A
  • total awarness of self and environment
  • arousal (alertness)
  • awareness (sum of cognitive mental functions)
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2
Q

consciousness depends on?

A
  • arousal of cerebral cortex by brainstem ascending reticular activating system (RAS)
  • input from sensory
  • projects to hypothalamus, thalamus, cortex
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3
Q

impaired consciousness means?

A
  • diffuse or b/l impairement of both hemispheres
  • failure of brainstem ARAS
  • both
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4
Q

confusion–what is it?

A

-orientation disturbed

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5
Q

delirium–what is it?

A

-hallucinations (visual)

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6
Q

obtundation–what is it?

A

-mental blunting, increased sleep, arouses to mild stimuli (voice)

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7
Q

stupor–what is it?

A

arouses only to noxious stimuli and not environmental

-only rudimentary awareness (purposeful motor responses)

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8
Q

coma–what is it?

A

-unarousable, unresponsive, unaware

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9
Q

persistent vegetative state

A
  • arousal, awarness
  • no reproducible response to stimuli
  • eyes may be open, eye movements
  • BP/pulse stable
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10
Q

akinetic mutism

A

-no spontaneous motor activity

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11
Q

locked in state

A
  • normal sensation/ cognition

- complete paralysis except vertical eye movements

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12
Q

hypertension–consider

A

-pheochromocytoma, drugs, increased ICP

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13
Q

hyperthermia consider

A

-infection, heat stroke, serotonin syndrome, pontine hemorrhage

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14
Q

breath odor–musty

A

hepatic failure

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15
Q

neuro exam–2 purposes

A
  • determine location and nature causing the impaired consciousness–anatomic level of brain involvement (supratentorial, subtentorial, diffuse)
  • narrow differential possibilities
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16
Q

broad categories of lesions that produce coma

A
  • supratentorial mass lesions–cause dysfunction in upper ARAS, cause downward herniation of brain to compress ARAS
  • infratentorial mass lesions–involve brainstem
  • diffuse/multifocal brain disease
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17
Q

supratentorial causes of coma

A
  • unilateral–subdural hematoma, brain abcess, tumor

- bilateral–subarachnoid hemorrhage, multiple infarcts, cerebral edema, acute hydrocephalus

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18
Q

subtentorial causes of coma

A
  • central pontine myelinolysis

- cerebellar hemorrhage/infarct, neoplasm, abcess

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19
Q

diffuse causes of coma

A

-hypoxia
-meningitis/encephalitis
-hypo/hyper-glycemia
-hyponatremia
-hepatic failure
-malignant hypertension
seizures (status epilepticus)

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20
Q

Neuro exam–essential elements

A
  • pupillary responses
  • corneal reflex
  • extraocular movements
  • cough/gag reflex
  • motor responses
  • resp pattern
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21
Q

Neuro exam–nearly essential elements

A
  • neck stiffness
  • carotid auscultation
  • fundoscopic exam
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22
Q

pupillary response–sympathetic path

A
  • hypothalamus
  • lower cervical cord
  • sympathetic chain
  • superior cervical ganglion
  • up carotid artery to CN V1, long cilicary nerve (dilator)
  • Mueller’s muscle
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23
Q

pupillary response–parasympathetic path

A
  • upper midbrain (edinger westphal nucleus)
  • CN III
  • ciliary ganglion
  • short ciliary nerve (constrictor)
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24
Q

symp and parasymp pathways for pupillary response–anatomically adjacent to?

A
  • ARAS

- absent or unequal responses imply brainstem lesion!!

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25
dilated pupil on 1 side
-parasymp (CN III)
26
dilated pupil bilaterally
- b/l lesion to CN III - post ictal - barbiturate intoxication
27
constricted pupil
-symp dysfunction
28
pinpoint pupil
- pontine lesion - opiates - pilocarpine (3Ps)
29
midposition and unreactive pupil
symp and parasymp (midbrain)
30
frontal gaze, pontine gaze
- frontal--deviate eyes to opp side | - pontine--deviate eyes to same side
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roving--conjugate, dysconjugate
- conjugate--brainstem intact | - dysconjugate--brainstem lesion
32
conjugate deviation at rest--hemispheric lesion
- destructive--toward lesion | - irritative-away from lesion
33
conjugate deviation at rest--brainstem lesion
-destructive--away from lesion
34
oculocephalic maneuver (dolls eyes)
Mid pons! - CN 3,4,6 - horizontal/vertical head rotation--eyes move opposite
35
caloric (oculovestibular) reflex
``` Lower pons! -irrigate TM with cold water -eyes deviate to irrigated side -eye deviate downward if b/l irrigation (brainstem intact!) ```
36
decorticate?
arms flexed, legs extended | -hemispheric/ corte lesion
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decerebrate
all extremities extended | -brainstem
38
flaccid?
pontomedullary or metabolic
39
Cheynes Stokes
- b/l hemispheres or diencephalon | - crescendo-decrescendo breathing pattern--hyperpnia alternating with apnea
40
stupor and coma--4 broad categories
- supratentorial - subtentorial - diffuse/metabolic - psychiatric unresponsiveness
41
supratentorial mass lesions--characteristics
- focal! - neuro signs--1 anatomic location - progression of signs rostral to caudal - motor signs--asymmetric
42
herniation syndromes caused by?
expanding supratentorial mass lesions | -displace brain tissue--rostral to caudal progression
43
uncal transtentorial
uncus under tentorium | -compress CN III, contralateral brainstem (ipsilateral hemiparesis), resp abnormalities
44
central transtentorial
herniate into foramen magnum | -resp arrest, death
45
cingulate gyrus
-herniates under falx
46
subtentorial mass lesions characteristics
- localizing brainstem signs preceed coma--always include oculovestibular abnormality (eye movement) - CN palsies usually present - bizarre respiratory patterns
47
diffuse/metabolic characteristics and causes
- confusion, stupor precede motor signs - motor signs symmetrical - pupillary reactions preserved!! - asterixis (liver flap-flaps wrist down and up), myoclonus - acid-base imbalance ``` hepatic/renal failure -hyper/hypoglycemia -hypoxia electrolyte imbalance--hyper/hyponatremia, calcium -sepsis ```
48
global cerebral ischemia
- blood flow inadequate to meet metabolic requirements of brain (cardiac, pul arrest) - ranges from reversible to brain death
49
global cerebral ischemia reversible when?
-
50
prolonged ischemic episodes
- comatose at least 12 hours | - lasting focal or multifocal motor, sensory, cognitive deficits
51
persistent vegetative state
- awake but functionally decorticate, unaware of surroundings - eye opening, eye movements, sleep-wake cycles
52
brain death definition
- irreversibility - complete cessation of brain function (including respirations but not heartbeat) - persistance
53
irreversibility--what must be ruled out?
-cause of coma known--irreversible | sedative intoxication, hypothermia (
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cessation of brain function
- unresponsiveness to all sensory input | - absent brainstem reflexes--respiratory responses absent 8-10 minutes after patients pCO2 rises to 60 mmHg
55
absent brainstem reflexes
- pupillary light reflex-2,3 - dolls eyes, cold water irrigation--3,6,8 - pain reflex, pinch supraorbital n--5,7 - corneal reflex--5,7 - gag reflex--9,10
56
brain death--persistence
- 6 hours with confirmatory isoelectric (flat) EEG - 12 hours without confirmatory EEG - 24 hours for anoxic brain injury without confirmatory EEG
57
manage comatose patients--1st steps
- A-patent airways - B-breathing, oxygenation - C-circulation, bleeding
58
manage comatose patients--next steps
- history, exam, EKG - glucose, thiamine - antidote - adjust body T - control agitation - stop seizures if present
59
manage comatose patients--Lab evaluation
- venous blood--glucose, electrolytes, BUN/creatinine, osmolality, drug screen, liver function, ammonia, coagulation studies, blood cultures - arterial blood--pH, pO2, pCO2, HCO3, HbCO - urine--UA, culture, drug screen - if febrile--blood cultures - if stiff neck--LP after CT
60
manage comatose patient--diagnostic testing
- non-contrast CT (blood, space occupying lesion) - LP (xanthochromia--hemorrhage, infection) - MRI (posterior fossa, infarct)--not done right away! - EEG--if expect seizures
61
manage comatose patient--specific interventions--reduce elevated intracranial P
- elvate head of bed - intubate/hyperventilate to PCO2 of 20 mm (constricts BVs) - mannitol for ischemic lesions (hyperosmolar conc--will suck water/edema out of brain) - decadron for tumor, abcess, cerebral hemorrhage - Lasix--for dehydration
62
manage comatose patient--specific interventions--treat seizures
- lorazepam | - phenytoin
63
glascow coma sclae
(3-15) - eye opening--1-4 - best verbal response-1-5 - best motor response-1-6
64
KEY to accuracy in diagnosis and management lies in 2 steps
- physical signs--determine anatomic level of brain involvement - determine supratentorial, subtentorial, or metabolic
NS2 Test 3
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