Ams And Coma; Headaches

Front 1

Altered mental state - generic term

Back 1

Encephalopathy

Front 2

Lethargy: defn

Back 2

Arousal is diminished but maintained spontaneously or with repeated LIGHT stimuli.

In low stimuli, patient drifts slowly into unconsciousness

Front 3

Obtundation: defn

Back 3

Arousal is decreased with some purposeful response to touch or verbal stimuli

Front 4

Stupor: defn

Back 4

State of severely impaired arousal with some purposeful response to VIGOROUS stimuli. Patient immediately drifts into unconsciousness once stimuli is removed.

Front 5

Order from least to most severe:
Obtundation
Stupor
Coma
Lethargy

Back 5

Lethargy
Obtundation
Stupor
Coma

Front 6

Reticular activating system: defn

Back 6

responsible for phys of arousal. Poorly localized network of cells in rostral brainstem and diencephalon

Front 7

Big 3 causes of coma

Back 7

Stroke

Cranial Trauma

Drug intoxification

Front 8

2 broad coma categories

Back 8

1) Structural/Surgical - increased ICP or diffuse vascular damage

2) Metabolic/Medical - diffuse insult from either endo- or exogenous toxin.

Front 9

Which deficiency states can produce coma?

Back 9

Thiamine (Wernicke's encephalopathy); Niacin (pellagra)

Front 10

Coma followed by lucid interval then deepening stupor - think what?

Back 10

Epidural hematoma due to middle meningeal a. hemorrhage

Front 11

opisthotonus: defn

Back 11

Severe hyperextension and spasticity in which an individual's head, neck and spinal column enter into a complete "bridging" or "arching" position.

This abnormal posturing is an extrapyramidal effect and is caused by spasm of the axial muscles along the spinal column.

Front 12

In the PE of skin of someone with AMS/Coma, what could the following indicate?
A) Pallor
B) Rubor
C) Flushing
D) Cyanosis
E) Icterus

Back 12

A) Anemia, shock, syncope
B) HTN
C) Fever
D) Cardiac disease, pneumonia, electrical shock
E) Liver disease

Front 13

Temp may rise with what two causes of coma?

Back 13

1) Septic shock/infection

2) SAH

Front 14

____________ is seen with HTN in increased ICP.

Back 14

Bradycardia

Front 15

3 domains of Glasgow Coma Scale (GCS)

Back 15

Eye Opening
Verbal
Motor

Front 16

Decorticate posturing is characterized by what?

Back 16

Abnormal (spastic) flexion

Patients with decorticate posturing present with the arms flexed, or bent inward on the chest, the hands are clenched into fists, and the legs extended and feet turned inward

Front 17

Decerebrate posturing is characterized by what?

Back 17

Extensor (rigid) response

It describes the involuntary extension of the upper extremities in response to external stimuli. In decerebrate posturing, the head is arched back, the arms are extended by the sides, and the legs are extended.

EXTENDED ELBOWS especially

Front 18

GCS for
A) Mild
B) Moderate
C) Severe
brain injury

Back 18

A) 13+
B) 9-12
C) <8

Front 19

Three clinical indicators of brainstem dysfunction to help differentiate brainstem coma vs. metabolic coma

Back 19

1) Abnormal breathing patterns
2) Abnormal pupillary responses
3) Abnormal eye movements

Front 20

Cheyne-Stokes Breathing: defn and use

Back 20

Defn: Oscillation between hypo and hyperventilation

Use: Occurs in coma from bilateral or diencephalic insult but may occur due to damage anywhere <b>between forebrain and pons </b>.

Front 21

Diffuse Microvascular Abnormality causing coma occurs in what diseases?

Back 21

Thrombotic thrombocytopenic purpura

Rocky Mountain spotted fever

Cerebral malaria

Front 22

Short-cycle Breathing: defn and cause

Back 22

Defn: Similar to Cheyne-Stokes but faster cycling between hypo- and hyperventilation.

Use: Occurs in increased ICP, expanding posterior fossa lesions, or lower pontine lesions

Front 23

Central Neurogenic Hyperventilation: defn and cause

Back 23

Defn: RR of 40-70

Use: Results from lesions of central tegmentum of pons (ventral to aqueduct or 4th ventricle)

Front 24

Apneustic Breathing: defn and cause

Back 24

Defn: Prolonged inspiratory gasp with pause at end, followed by expiration

Use: Caused by lesions of dorsolateral lower half of pons

Front 25

Cluster Breathing: defn and cause

Back 25

Defn: Periodic breathing with irregular frequency and amplitude with variable pauses between clusters of breaths

Use: Caused by high medullary damage

Front 26

Ataxic Breathing: defn and cause

Back 26

Defn: Irregular in rate and rhythm

Use: Caused by medullary lesions. Preterminal pattern.

Front 27

most important part of coma exam

Back 27

Evaluation of pupils

Front 28

If pupils are reactive to light, what type of coma?

Back 28

Almost always metabolic/medical

Imminent brain herniation or neurosurgical emergency unlikely

Front 29

Lesions below the ____ and above the _____ usually don't cause pupillary abnormalities (except Horner syndrome from medullary or cervical spinal damage).

Back 29

pons; thalamus

Front 30

Unreactive, unequal, dilated pupil may be a sign of what?

Back 30

Uncus herniation (part of temporal lobe). The herniating uncus presses on CN III --> failure of parasympathetic innervation of eye.

Neurosurgical emergency

Front 31

_____ lesions disrupt sympathetic paths and cause pinpoint pupils.

Back 31

Pontine

Front 32

Skew deviation: defn and significance

Back 32

vertical displacement of eyes. Usually indicates brainstem lesion.

Front 33

3 steps of eye movement evaluation

Back 33

1) Observe resting position of eyes

2) Evaluate spontaneous movements

3) Investigate reflex eye movements

Front 34

___ eye movements are usually seen in metabolic encephalopathies or bilateral lesions above the brainstem

Back 34

Roving, slow, conjugate, lateral to-and-fro

Front 35

Ocular bobbing : defn and significance

Back 35

rapid downward jerk of both eyes, followed by slow return to midposition

Indicative of pontine dysfunction, generally.

Front 36

Paralysis of spontaneous and lateral eye movements associated with _____ lesions

Back 36

acute pontine

Front 37

Inverse ocular bobbing or ocular dipping, which consists of a slow downward phase followed by a rapid upward phase and preserved reflex eye movements, is often associated with diffuse _____ damage

Back 37

cerebral

Front 38

Determining if reflex eye movements are present involves the ______ maneuver.

Back 38

Doll's eye

Front 39

Direction of fast nystagmus movement with cold water and warm water if brainstem is intact

Back 39

Cold - opposite

Warm - same

Front 40

T/F Spontaneous motor movements are always good prognostic signs

Back 40

T

Front 41

Decorticate posturing suggests a lesion (above, below) the brainstem.

Back 41

Above. Better prognosis than decerebrate.

Front 42

Decerebrate posturing suggests lesion where?

Back 42

bilateral midbrain or pontine lesion

Front 43

The combination of deep coma (even with total flaccidity or abnormal posturing) and briskly reactive pupils almost always means a ____ coma

Back 43

non-brainstem metabolic

Front 44

The combination of deep coma and spontaneous eye movements almost always means a ____coma.

Back 44

non-brainstem metabolic

Front 45

The combination of coma and brisk pupillary reflexes and poor/absent eye movements strongly suggests a ___ coma

Back 45

sedative drug overdose

Front 46

An uncomfortable-looking patient and fixed mid-position/large pupil and absent eye movements and abnormal breathing pattern +/- coughing/swallowing/hiccupping motions suggests ___ coma

Back 46

brainstem

Front 47

The combination of deepening coma and unilateral dilating pupil (or a unilateral dilated pupil not due to mydriatics or eye disease) suggest ____

Back 47

rapidly expanding supratentorial process and secondary transtentorial herniation until proved otherwise

Front 48

Every patient with coma of unknown cause should undergo what test?

Back 48

1) Immediate fingerstick for blood glucose

2) Metabolic panel (electrolytes, liver function

3) CBC + differential

4) Coagulation profile

Front 49

History of seizures or there is eyelid blinking or unexplained nystagmus, an EEG may determine if ____ is the cause of the coma

Back 49

nonconvulsive status epilepticus

Front 50

Diffuse slowing on the EEG may indicate a ____

Back 50

metabolic encephalopathy

Front 51

Periodic lateralized epileptiform discharges (PLEDs) on EEG may suggest _____.

Back 51

herpes simplex encephalitis

Front 52

____ causes of coma has best prognosis

Back 52

Metabolic (assuming it can be corrected)

Front 53

Favorable signs if they occur during coma:

Back 53

1) ANY type of speech, even if incomprehensible

2) Orienting spontaneous eye movements

2) Obeying commands

3) Normal reflexes

Front 54

T/F Length of coma in patients with traumatic injury implies poor prognosis.

Back 54

F. Not necessarily.

Front 55

_____ pattern on EEG between 6 and 24 hours after anoxic injury are associated with poor outcome

Back 55

burst-suppression pattern

Front 56

Alpha coma: defn and significance

Back 56

looks like normal alpha rhythm but an essentially unaroused patient

Mortality rate is higher (especially after hypoxic injury or TBI)

Front 57

T/F Appearance of normal sleep patterns, even in hypoxia, is associated with lower mortality

Back 57

T

Front 58

_____ evoked potentials is strongly associated with instance of vegetative state or death regardless of cause.

Back 58

Bilaterally absent cortical somatosensory

Front 59

Permanent vegetative state: defn

Back 59

Normal sleep-wake cycles and eyes that open to verbal stimuli but no cognitive function. Can't localize pain or follow commands.

Front 60

Locked-in syndrome: defn

Back 60

Conscious of environment but unable to move, talk, or have horizontal eye movements. May have vertical eye movements and blinking

Front 61

Locked-in syndrome: location of lesion and cause

Back 61

Lesion in brainstem involving motor paths, efferent abducens (CN 6) nerve fibers, and corticobulbar fibers.

Common causes: pontine infarct from basilar artery.

Front 62

Locked-in syndrome: Eye movements mostly likely to be preserved

Back 62

Vertical

Front 63

Akinetic Mutism: defn and cause

Back 63

patient lies speechless and motionless in bed and appears to be asleep and can be aroused

Descending motor paths are INTACT.

Lesions of thalamus, cingulate gyri, upper brainstem.

Front 64

Minimally Conscious State: defn

Back 64

Condition of severely altered consciousness in which the person demonstrates minimal but definite behavioral evidence of self- or environmental awareness

Front 65

Patients in a minimally conscious state are able to do the following:

Back 65

1. follow simple commands
2. gesture or verbally give “yes” or “no” responses (regardless of accuracy)
3. verbalize intelligibly
4. perform movements or affective behaviors, which are not attributable to reflexive activity, in contingent relation to relevant environmental stimuli.

Front 66

Hysteria: defn

Back 66

loss of consciousness is not deep and rarely complete
reflexes are normal
Corneal and pupillary responses are normal
eyes kept firmly shut

Front 67

Primary vs. Secondary Headache

Back 67

Primary: idiopathic, most are benign

Secondary: caused by other conditions (infection, hemorrhage, etc)

Front 68

SNOOPP for secondary headaches

Back 68

Systemic symptoms

Secondary risk factors

Neurologic symptoms (AMS, etc)

Onset - sudden

Older patient

Previous headache

Postural

Front 69

Migraines: age of onset

Back 69

Usually in teens (before age 20 in half)

Front 70

About ___% of migraines preceded by aura.

Back 70

20

Front 71

Aura: defn

Back 71

Complex of focal neurologic sx preceding, accompanying (or rarely following) migraine

Front 72

Most common auras

Back 72

Visual - blind spots, zigzag lines, flickering, tunnel vision, etc

Front 73

When is CT scan warranted for headache?

Back 73

If suspect acute bleed

Front 74

In patients with recurrent migraine, and normal exam, neither CT nor MRI is warranted except in cases with:

Back 74

1) Focal neurologic symptoms
2) Recent substantial change in HA pattern
3) History of seizures

Front 75

Lumbar puncture in headache - when?

Back 75

1) 1st unusually severe HA

2) Thunderclap HA with normal CT

3) Subacute progressive HA

4) HA + fever, confusion, seizures

5) High or low CSF pressure suspected (even if papilledema is absent)

Front 76

Migraine: associated sx

Back 76

Photophobia and phonophobia

Nausea and/or vomiting

Front 77

Migraine: Clinical Features

Back 77

Lasts 4- 72 hours

At least 2 of following:
Unilateral, Pulsating quality, Mod-Sev pain intensity, Aggravation by routine physical activity

At least 1 of following:
Photophobia and phonophobia

Nausea and/or vomiting

Front 78

Role of 5HT in migraine

Back 78

Depletion can trigger attack.
IV 5HT can abort acute migraine attack.

Front 79

Triptans: MOA

Back 79

Agonists at 5-HT 1B and 1D receptors

Front 80

Preventive drugs for migraine:

Back 80

Topiramate

Divalproex

Timolol

Propranolol

Methysergide

Front 81

Symptomatic meds to be taken after migraine has started

Back 81

-Triptans

Front 82

Most common primary headaches

Back 82

Tension HAs

Front 83

Tension HAs: symptoms

Back 83

Bilateral pain that feels pressing or tightening and mild-moderate in intensity.

Does NOT worsen with physical activity

Increased pericranial tenderness with palpation

Front 84

Difference between tension HA and migraine

Back 84

Tension HA NOT worsened by routine physical activity.

Migraines more severe.

Tension HAs have no more than one of the following: photophobia, phonophobia, mild nausea

Migraines often unilateral.

Front 85

Chronic tension HA: dx criteria

Back 85

Headache occurs at least 15 days/month on average for >3 months

Front 86

Cluster headache : clinical features

Back 86

Attacks of severe, excrutiating, STRICTLY unilateral pain in PERIORBITAL region. Last 15-180 minutes.

Occurs from once every other day - eight times/day.

Front 87

Cluster headache : associated symptoms

Back 87

IPSILATERAL

Conjunctival injection
Lacrimation
Nasal congestion
Rhinorrhea
Forehead and facial sweating
Ptosis
Miosis
Eyelid edema

Front 88

Cluster headache : symptomatic treatment

Back 88

Because they're short acting, must have fast-acting symptomatic treatment

100% O2, Quickest-acting triptans (subcutaneous injection); Dihydroergotamine

Front 89

Cluster headache : prevention

Back 89

Verapamil, Lithium

Front 90

Trigeminal neuralgia: clinical presentation

Back 90

Brief unilateral stabs of pain

Distribution of one or more divisions of CN V

Triggered by minor stimulation

Patient is asymptomatic between paroxysms of pain

Front 91

Trigeminal neuralgia: Prevention

Back 91

Carbamazepine

Gabapentin

Baclofren

TCAs

Front 92

What is the gender predominance in the following disorders:
A) Migraine
B) Cluster HAs

Back 92

A) Women
B) Men

Front 93

Triptans: site of action

Back 93

site of action is the interface between trigeminal nerve endings and blood vessel walls