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DU PA Coma

Duke PA Coma

Consciousness requires an __ intact and functioning brain stem reticular activating system and its cortical projections
__ result in coma either by expanding across the midline laterally to compromise both cerebral hemispheres or by impinging on the brain stem to compress the rostral reticular formation hemispheric mass lesions
hemispheric lesions of adequate size to produce coma are readily seen on __ CT
__ produce coma by directly affecting the reticular formation brain stem mass lesions
a comatose patient without imparied reflex lateral eye movements does not have a __ mass lesion compromising brain stem structures in the posterior fossa
metabolic abnormalities result in diffuse dysfunction of the nervous system and therefore produce, with rare exceptions, __ no localized signs such as hemiparesis or unilateral pupillary dilation
the diagnosis of __ means that the examiner has found no focal anatomic features on examination or neuroimaging studies to explain coma metabolic encephalopathy
once a seizure stops the __ can also cause unexplained coma postictal state
leading up to coma a premonitory headache supports a diagnosis of __ meningitis, encephalitis, or intracerebral or subarachnoid hemorrhage
leading up to coma a period of intoxication, confusion, or delirium points to diffuse process such as meningitis, or endogenous or exogenous toxins
the sudden apoplectic onset of coma is particularly suggestive of ischemic or hemorrhagic stroke affecting the brain stem or of subarachnoid hemorrhage or intracerebral hemorrhage with intraventricular rupture
Lateral symptoms of hemiparesis or aphasia before coma occur in patients with hemispheric masses or infarctions
what are the three questions you want to ask yourself during physical examination of a coma patient does the patient have meningitis, are signs of a mass lesion present. is this condition a diffuse syndrome of exogenous or endogenous metabolic cause
__ should be carried out in all comatose patients unless a history of trauma exists passive neck flexion
when the neck is passively flexed, by attempting to bring the chin within a few finger breadths of the chest, patients with irritated meninges reflexively __ flex one or both knees (Brudzinski's reflex)
asymmetric or reflex function of the motor system provides the clearest indication of a __ mass lesion
methods used to evoke a pain response from a patient strong pressure on the supraorbital ridge or pinching of the skin on the anterior chest or inner arm
elicitation of a __ requires that a painful stimulus be applied to which the patient will react motor response
hemispheric masses at their early stage (compromising the brain above the thalamus) produce appropriate movement of one upper extremity, that is __ toward the stimulus
as the mass expands to involve the thalamus, the response to pain becomes reflex arm flexion associated with extension and internal rotation of the legs (decorticate posturing)
with late brain compromise at the midbrain level, the reflex posture changes in the arms such that __ at this level the asymmetry tends to be lost both arms and legs respond by extension (decerebrate posturing)
with further brain compromise progression to the level of the pons __ is the most frequent finding. no response to painful stimulation
in metabolic coma pupillary reactivity is lost only when __ coma is so deep the patient requires ventilitory and blood pressure support
with further brain compromise progression to the level of the pons pupils become __ midposition in size, and light reflex is lost, first unilaterally then bilaterally
the presence of inducible lateral eye movements reflects the integrity of the __ pons and midbrain
reflexive eye movements are brought about by __ passive head rotation to stimulate the semicircular canal input to the vestibular system (doll's eyes maneuver
lack of inducible lateral eye movement int he setting of preserved pupillary reactivity, is virtually diagnostic of __ drug toxicity
with metabolic coma of non-drug induced origin, such as organ system failure, electrolyte disorders, or osmolar disorders, reflex eye movements are preserved
brainstem mass lesions are most commonly caused by hemorrhage or infarction
seizures occurring in a patient with acute brain injury, or chronic brain injury often result in __ prolonged postictal coma
return of pupillary reactivity within 24 hours and purposeful motor movements withing the first 72 hours after cardiac arrest aqre highly correlated with __ favorable outcome
the slow, conjugate roving eye movements of metabolic coma cannot be imitated and therefore rule out __ psychogenic unresponsiveness
in patients with catatonic stupor __ administration may produce awakening lorazepam
in __, patients have awakened from coma but have not regained awareness persistent vegetative states
wakefulness is exhibited by __ eye opening and sleep wake cycles.
in __ the reticular activating system of the brain stem is intact to produce wakefulness, but the connections to the cortical mantle are interrupted, precluding awareness persistent vegetative state
a vegetative state is termed persistent after __ months if the brain injury was medical 3
a vegetative state is termed persistent after __ months if the brain injury was traumatic 12
__ characterizes the irreversible cessation of brain function brain death
brain death results in __, usually within days even if ventilatory support is continued. asystole
__ after appropriate documentation of brain death has never been reported recovery
clinical features of locked-in syndrome eye opening, reactive pupils, volitional vertical eye movements to command, mute, quadriparesis, sleep wake cycles
damage to hemispheres causes unresponsive and unreceptive to sensory stimuli including pain
damage to midbrain causes unreactive pupils
damage to pons causes absent reflex eye movements
damage to medulla causes apnea
definition of coma inability to sense or respond to external stimuli or inner needs
com is not a __ disease, it is an expression of an underlying pathological process
a high level function that permits understanding of self and environment. This function resides diffusely in the cerebral cortex. awareness
a more primitive function and refers to a primitive set of responses that are contained totally within the brainstem. arousal
for loss of consciousness to occur: __ either both cerebral hemispheres must be damaged or ther must be a brainstem lesion
causes of coma metabolic (drug ingestion, hypoglycemia)50%, cerebral hemorrhage 20%, cerebral infarction 10%, psychiatric 2%
causes of sudden onset of coma cardiac arrest, subarachnoid hemorrhage (secondary to aneurysm, brainstem infarct or hemorrhage, bicerebral hemispheric infarction
causes of coma onset over minutes to hours drug overdose, hypoxia, hypoglycemia, subarachnoid hemorrhage, acute hydrocephalus, vascular malformation, meningitis and encephalitis, metabolic (uremia, hepatic failure), hypertensive encephalopathy
Battle's sign retroauricular hematoma, indicates mastoid fracture
hemispheric or diencephalic dysfunction due to destructive lesions or metabolic abnormality. decorticate
suggests upper brain disfunction decorticate
arms move toward pain decorticate
suggest lower brain disfunction decerebrate
midbrain or upper pons dysfunction on a structural or metabolic basis. decerebrate
arms move away from pain decerebrate
type of breathing in bilateral hemispheric lesions. Most commonly seen in non-neurologic disorders (CHF). cheynes-stokes
reactive pupils indicate that the __ midbrain is intact
midposition (3-5mm) nonreactive pupils indicate midbrain damage
A unilaterally dilated, nonreactive pupil (a blown pupil) is a sign of __ cranial nerve III (oculomotor nerve) compression (Aneurysm, Mass Lesion).
A dilated nonreactive pupil may also be caused by diabetes mellitus and some drugs (atropine, scopolamine)
small reactive pupils are seen in __ pontine damage (infarct or hemorrhage) or with some drug use (opiates, pilocarpine).
bilateral midposition unreactive pupils can be seen with hypothermia
eye deviation occurs __ a unilateral hemispheric lesion toward
eye deviation occurs __ from a unilateral brainstem lesion away
function testing of eye movements is done by the __ the oculo-cephalic reflex (Doll's head) or oculo-vestibular reflex (ice water calorics).
normal oculocephalic reflex eyes move in the direction opposite to the movement of the rotating head
abnormal oculocephalic reflex suggests destructive lesion at the midbrain or pontine level
normal response to the oculo-vestibular reflex in a conscious patient Tonic (sustained) deviation of the eyes toward the stimulated side, with the quick phase of nystagmus toward the opposite side
response of a comatose patient with an intact brainstem to the oculo-vestibular reflex tonic deviation of the eyes will be present, but there will be no nystagmus
response of a comatose patient with brainstem dysfunction to the oculo-vestibular reflex Loss of tonic deviation with stimulation of one, or both ears. If there is no tonic deviation there can be no fast response.
abnormal response to corneal sensation suggests a pontine lesion
if a patient is comatose the first lab result should be glucose
lowest possible glasgow coma score (GCS), indicating deep coma or death 3
GCS of __ or lower suggests coma 8
highest GCS indicating fully awake 15
__ can be present in brain death deep tendon reflexes
physical exam findings in a pateint who is brain dead no purposeful movement, They demonstrate no pupillary responses, extraocular movements (spontaneously, or in response to stimulation), corneal reflexes, spontaneous respirations or movements (spontaneous or in response to stimulation).
GCS, is broken up into what catagories eye, verbal, and motor responses
GCS eye response: eyes open spontaneously = grade 4
GCS eye response: eye opening to speech (not to be confused with awakening a sleeping person) = grade 3
GCS eye response: eyes opening in response to pain = grade 2
GCS eye response: no eye opening 1
GCS verbal response: oriented (patient responds coherently and appropriately to questions) = grade 5
GCS verbal response: confused (the patient responds to questions coherently but there is some disorientation and confusion) = grade 4
GCS verbal response: inappropriate words (random or exclamatory articulated speech, but no conversational exchange) = grade 3
GCS verbal response: incomprehensible sounds (moaning but no words) = grade 2
GCS verbal response: no verbal response = grade 1
GCS motor response: obeys commands = grade 6
GCS motor response: localizes to pain (purposeful movements towards changing painful stimuli) = grade 5
GCS motor response: withdraws from pain (pull part of body away when pinched) = grade 4
GCS motor response: flexion in response to pain (decorticate response) = grade 3
GCS motor response: extension to pain (decerebrate response, adduction, internal rotation of shoulder, pronation of forearm) = grade 2
GCS motor response: no motor response = grade 1
almost all patients in coma will eventually __ wake up to some degree
in vegetative states the eyes may open in response to verbal stimuli and may appear to follow a light. however ther will be __ no response to visual threat
patients in a vegetative state do not __ discretely localize motor responses, follow commands or speak comprehensibly
Created by: bwyche