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coma
CBN II
34
Medical
Graduate
01/29/2011

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Term
what is a difference between the comatose evaluation and general neurologic exam? (*know this*)
Definition
the sensory, motor, and reflex evaluations are grouped separately in the neurologic exam, but are grouped together in the comatose exam.
Term
what are the top 3 most important tests in the evaluation of a comatose pt? (*know this*)
Definition
LOC, **eye exam (pupils, EOM, fundi, corneal reflex), and motor/sensory/reflex
Term
what is delirium? (*know this*)
Definition
a condition characterized by disorientation, fear, irritability, and misperception of sensory stimuli w/associated visual hallucinations
Term
what is the "state of consciousness"? (*know this*)
Definition
a statement of the pt's actual behavioral response, usually determined by the glasgow coma scale - based on eye opening, verbal and motor responses. the lowest state is 3 and the highest is 15 (eyes 4, mouth 5, body 6 ).
Term
what is the simple pathway when considering locations in neuro pathology?
Definition
cerebral hemis, midbrain, pons, medulla, spinal cord, nerve roots, peripheral nerves, neuromuscular junction and muscle
Term
what is the difference between the glasgow coma scale and comatose evaluation? (*know this*)
Definition
glasgow coma scale really just evaluates the level of consciousness
Term
what is the difference between coma and locked in syndrome?
Definition
in locked in syndrome the lesion is in the ventral pons and the pt is awake/alert - they just can't move extremities or face.
Term
what is cheyne-stokes breathing? (*know this*)
Definition
crescendo, decrescendo and apnea in breathing pattern = diffuse bilateral hemisphere dysfunction (non-localized). can be related to drug OD or just "normal" during sleep for some pts.
Term
what is biot's breathing? (*know this*)
Definition
irregularly irregular breathing (like a-fib) due to a lesion in the medulla (terminal breathing).
Term
what characterizes BP in a comatose pt?
Definition
increasing ICP will result in an elevation the systolic blood pressure, and a widening of the pulse pressure.
an increasing ICP will result in a slowing of the pulse (bradycardia) initially, and if there is a tachycardia in the presence of an increased ICP without hypovolemia, this usually is grave prognostic sign.
Term
what characterizes respiration in a comatose pt?
Definition
an increasing ICP will initially slow the respiratory rate, however, with severe increase in ICP, the patient may demonstrate a tachypnea.
Term
what is the path of the sympathetics running to the pupillary constrictors?
Definition
this sympathetic system begins in the hypothalamus, travels through the brainstem to the lower cervical spine cord region, (first order neuron), and then leaves the CNS. it then will traverse over the apex of the lung, under the subclavian artery, and eventually arrive at the superior cervical ganglion (second order neuron). the third order neuron will then accompany the carotid systems (both internal and external) to its final destinations (CN3 -> pupillary constrictors). if these sympathetics are impaired, the pupils are smaller (miosis), but still reactive to light.
Term
what is horner's syndrome? (*know this*)
Definition
miosis, ptosis, anhydrosis (little eye, little pupil, little sweat)
Term
what is lateral medullary syndrome?
Definition
aka wallenberg's - ataxia due to cerebellar dysfunction: 4 D's (dysphagia, dysarthria, diplopia, and dizziness)
Term
what is a pancoast tumor?
Definition
a tumor of lung pushing on to sympathetics, giving a horner’s syndrome on that side (outside CNS). also possible w/direct trauma to the internal carotid.
Term
what is the path of the parasympathetics running to the pupillary dilators?
Definition
afferent and efferent nerves enter CN2, and the efferent portion with CN3. there is a crossover of the afferent system, both at the optic chiasm and in the tectum of the mid-brain.
Term
what does fixed pupils imply?
Definition
knocked out parasympathetics and sympathetics
Term
w/H-test, what does 1 eye not going medially when the other eye is going laterally imply?
Definition
lesion of CN3
Term
what does a CN3 injury tell you?
Definition
likely an issue w/the midbrain (likely MS)
Term
what does a CN6 injury tell you?
Definition
likely an issue w/the pons (likely MS)
Term
what does an issue w/the vestibular nucleus tell you?
Definition
likely an issue w/the medulla (likely MS)
Term
what is next if the pt has a negative doll's eye reflex (oculocephalic reflex: CN3+6)?
Definition
oculovestibular reflex - not caloric test (COWS) if pt is in a coma - but the pt's eyes should look toward the ear you put cold water in (CN6). if the eye stays there = CN3 involvement.
Term
what are you looking for in a funduscopic exam?
Definition
optic disk swelling, hemorrhage (flamed shaped: in retinal layer [DM] or subhyloid: between retinal and vitreous later [SAH]), exudates (cotton woll = severe disease), which can reflect HTN and diabetes
Term
what is corneal reflex?
Definition
CN5: sensory, CN7: lid shutting. bell's phenomenon - eye rolling back to protect itself.
Term
what characterizes motor/sensory/reflex examination in comatose pts?
Definition
appropriate response is pulling away from noxious stimulation - but inappropriate: absent (acute injury), decorticate (flexion/abduction = above red nucleus), or decerebrate (jaw clenched/neck retracted/arm+leg extension+internal rotation = below red nucleus)
Term
what are the major categories of pathology leading to a comatose state?
Definition
content (cerebral) or state of arousal (brainstem). pathology here is usually either supratentorial, subtentorial or metabolic [**most common**] (also possibly psychological).
Term
what characterizes supratentorial mass lesions? (*know this*)
Definition
those which secondarily encroach upon deep diencephalic structures so as to compress or damage the physiological ascending reticular activating system. this includes SDH, ICH (aneurysm or amyloid angiopathy) = **4 types of herniation: cingulate gyrus (herniates under falx), uncal (herniating over falx), central (herniates straight down) or tonsillar (herniates through foramen magnum). (also transcalvarial – if pt has skull fracture or skull removed to give brain space and it’s swelling outside).
Term
what characterizes subtentorial mass or destructive lesions?
Definition
direct damage to brainstem central core
Term
what characterizes metabolic disorders?
Definition
those which widely depress or interrupt brain function
Term
what is a duret's hemorrhage?
Definition
hemorrhage in the brainstem due to herniation of the brain
Term
what is kernahan's notch?
Definition
start out with right hemisphere lesion that gives left side weakness, left side hyperreflexia, left extensor toe response - as uncus herniates over, get dilated pupil on right, 3rd nerve palsy on right - as the brainstem gets pushed over the left side gets injured on the tent because it can’t move (started out with right hemisphere lesion, left side symptoms, but when the notch forms, develop right side symptoms).
Term
what is the one big subtentorial lesion?
Definition
brainstem infarct
Term
what are the metabolic etiologies leading to coma?
Definition
hypoxia, sepsis, exogenous toxins, and endogenous toxins
Term
what is the most important thing in tx of coma pts? (*know this*)
Definition
maintain vital function
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