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DU PA Coma
Duke PA Coma
| Question | Answer |
|---|---|
| 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
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