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Coma Signs
Neurology
| Question | Answer |
|---|---|
| Awareness vs arousal | awareness: high level fn (resides diffusely in cerebral cortex); arousal: primitive (brainstem) |
| For LOC to occur: | Both cerebral hemispheres damaged OR brainstem lesion |
| Coma: causes | Cerebral infarction 10%; Cerebral hemorrhage 20%; Metabolic causes 50% (Drug ingestion >50%; Hypoglycemia 5-10%); Psych 2% |
| Coma: sudden onset d/t: | Cardiac arrest; SAH; 2nd to aneurysm; Brainstem infarct or hemorrhage; Bicerebral hemispheric infarction |
| Coma: onset over min-hrs d/t: | usually drug overdose; also hypoxia; hypoglycemia; SAH; hydrocephalus; AVM; meningitis; metab |
| Head trauma sx | Battle (mastoid); raccoon eyes (orbital) CSF rhinorrhea/ otorrhea (basilar) |
| Roth spots | sx of septic emboli; on funduscopic exam & btw toes |
| Hollenhorst plaque | chol emboli from carotid |
| Coma: sensation: may see: | Purposeful withdrawal bilaterally; absent response Unilaterally; facial Grimace; posturing |
| Decorticate posturing: | hemispheric or diencephalic dysfn d/t destructive lesions or metabolic abnormality; hands come up (response to stimuli) but do not localize |
| Decerebrate posturing: | midbrain or upper pons dysfunction on a structural or metabolic basis; wrists flex (response to stimuli), not localizing |
| Cheynes-Stokes: | Bilateral hemispheric lesions; most commonly seen in non-neurologic disorders (CHF); crescendo-decrescendo |
| Central neurogenic hyperventilation: | Commonly metabolic cause (Sepsis; DKA) |
| Apneustic: | Rare, but usually associated with pontine infarction; pt breathes in, holds breath 15-20 sec, breathes out |
| Ataxic breathing (Biot's respiration) | Damage to the medullary respiratory centers; breathing slows; long breathless pause; then inhales; this is often premorbid |
| Most common reason for noting unreactive pupils: | an inadequate light source |
| Reactive pupils = | midbrain is intact. |
| Intact pupillary responses in unresponsive pt w/ absent EOM & corneal responses: | metabolic abnormality (e.g., hypoglycemia) or drug ingestion (e.g., barbiturate) |
| Midposition (3-5mm) nonreactive pupils = | midbrain damage. |
| Blown Pupil | unilaterally dilated, nonreactive pupil: sx of CN III (oculomotor nerve) compression (Aneurysm, Mass Lesion); dilated nonreactive pupil may also be caused by DM & some drugs (esp atropine, scopolamine) |
| Small, reactive pupils: seen in: | pontine damage (infarct or hemorrhage) or with some drug use (opiates, pilocarpine). |
| Bilateral midposition unreactive pupils: | hypothermia |
| Eye deviation occurs in what direction? | toward a unilateral hemispheric lesion and away from a unilateral brainstem lesion. |
| Functional testing of Eye Movements is done by: | oculo-cephalic reflex (Doll's head) or oculo-vestibular reflex (ice water calorics) |
| Oculo-cephalic reflex (Doll's head): CI | if there is a question of cervical spine injury |
| Oculo-cephalic reflex: Abnormal response = | absent or asymmetric eye movement: destructive lesion at midbrain or pontine level; poss also deep barbiturate poisoning |
| Oculo-vestibular reflex: Normal response (conscious pt): | Tonic (sustained) deviation of eyes toward stimulated side, w/ quick phase of nystagmus toward the opposite side |
| Oculo-vestibular reflex: Response in comatose pt w/ intact brainstem: | Tonic deviation of eyes, but no nystagmus |
| Oculo-vestibular reflex: Response in comatose pt w/ brainstem dysfn: | Loss of tonic deviation w/ stimulation of one, or both ears; if there is no tonic deviation there can be no fast response |
| Oculo-vestibular response does not: | distinguish between metabolic and structural causes of coma |
| Corneal sensation: | carried by CN V (Trigeminal); test with cotton swab pressed gently onto cornea; abnormal reponse suggests a pontine lesion |
| Coma: labs | GLUCOSE, lytes, renal, Ca, PO4, ABG, CBC, tox screen; CXR, imaging (after stabilization) |
| GCS: 3 tests | Eye, verbal, motor; range: 3-15; <8 means coma |
| GCS: eye | 1: no eye opening; 2: open in response to pain; 3: in response to voice; 4: open spontaneously |
| GCS: verbal | 1: None; 2: Incomprehensible sounds; 3: Inappropriate words; 4: confused; 5: oriented |
| GCS: Motor | 1: no response; 2: extension to pain; 3: flexion in response to pain; 4: withdraws from pain; 5: localizes to pain; 6: obeys commands |
| Brain death | no purposeful movements, pupil responses, EOM, corneal reflexes; spont resp / movements; DTRs may be present |
| Coma & sleep | Almost all coma pts will wake up to some degree; most develop a sleep-wake cycle |
| Coma: causes | Cerebral infarction 10%; Cerebral hemorrhage 20%; Metabolic causes 50% (Drug ingestion >50%; Hypoglycemia 5-10%); Psych 2% |
| Decorticate posturing: | hemispheric or diencephalic dysfn d/t destructive lesions or metabolic abnormality; hands come up (response to stimuli) but do not localize |
| Decerebrate posturing: | midbrain or upper pons dysfunction on a structural or metabolic basis; wrists flex (response to stimuli), not localizing |
| Cheynes-Stokes: | Bilateral hemispheric lesions; most commonly seen in non-neurologic disorders (CHF); crescendo-decrescendo |
| Central neurogenic hyperventilation is 2/2: | Commonly metabolic cause (Sepsis; DKA) |
| Apneustic = | Rare, but usually associated with pontine infarction; pt breathes in, holds breath 15-20 sec, breathes out |
| Ataxic breathing (Biot's respiration) | Damage to the medullary respiratory centers; breathing slows; long breathless pause; then inhales; this is often premorbid |
| Most common reason for noting unreactive pupils: | an inadequate light source |
| Reactive pupils = | midbrain is intact |
| Intact pupillary responses in unresponsive pt w/ absent EOM & corneal responses: | metabolic (e.g., hypoglycemia) or drug ingestion (e.g., barbiturate) |
| Midposition (3-5mm) nonreactive pupils = | midbrain damage |
| Blown pupil = | unilaterally dilated, nonreactive pupil: sx of CN III (oculomotor nerve) compression (Aneurysm, Mass Lesion); dilated nonreactive pupil may also be 2/2 DM or drugs (atropine, scopolamine) |
| Small, reactive pupils: seen in: | pontine damage (infarct or hemorrhage) or with some drug use (opiates, pilocarpine). |
| Bilateral midposition unreactive pupils: | hypothermia |
| GCS: 3 tests | Eye, verbal, motor; range: 3-15; <8 means coma |
Created by:
Abarnard
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