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