Nervous System (Block 6): Goodman Lectures On Altered Levels Of Consciousness

Front 1

Loss of consciousness occurs if what 2 things happen?

Back 1

1) both cerebral hemispheres are damaged OR
2) brainstem reticular activating system is damaged

Front 2

the rate of dz progression may give etiologic clues:
1) abrupt onset-rapid resolution
2) abrupt onset-slow/no resolution
3) subacute onset-progressive
4) chronic progressive

Back 2

1) vascular/seizure
2) vascular, trauma
3)tumor, infection, demyelinating
4) tumor, degenerative, infection, demyelinating

Front 3

what are the diagnostic possibilites from every major etiologic category of dz? (8)

Back 3

Neoplasm
Infectious/inflammatory
Vascular
Demyelinating
Toxic/metabolic
Degenerative
Trauma
Developmental

"NIV DTDTD"

Front 4

define: delirium, stupor, coma

Back 4

delirium: impaired ability to comprehend events in environment, hypervigilant, may have hallucinations, pt spontaneously interacts with environment

stupor: pt doesn't spontaneously interact with environment & asleep. two kinds: can be responsive to verbal stim or responsive to painful stim

coma: pt doesn't interact with environment & unresponsive to loud verbal or painful stimuli

Front 5

what does delirium usually indicate?

Back 5

bilateral cerebral hemispheric dysfunction with intact brainstem activity

Front 6

as LOC keeps going down what do you have to protect?

Back 6

their airway (they could aspirate something and die or may stop breathing). may have to intubate.

Front 7

what happened here? what would this show up as clinically?

Back 7

bullet shot causing bilateral hemorrhagic lesion in cerebellar. pt placed immediately into coma

Front 8

whats the pathology here? what happens clinically?

Back 8

hemmorhagic stroke that started focally but spread to the other side. as it takes down BOTH HEMISPHERES, then pt will begin to lose consciousness!!

Front 9

what is the pathology here?

Back 9

hydrocephalus leading to thinned cortex, basal ganglia w/ diminished size. pt experienced protracted period of lack of circulation to the brain; in a vegetative state. They’ve lost both hemispheres required to sustain consciousness.

Front 10

what's the pathology here? what does it show as clinically?

Back 10

Massively abnormal brainstem - pt may be in coma bc of tumor in the brainstem interfering with reticular activating system, leading to LOC. They’ll have cross-findings and LOC as RAS gets knocked out.

Front 11

what are the prerequisites for declaring a pt brain dead? (4)

Back 11

- Clinical or imaging features of CNS catastrophe
- Exclusion of medical conditions that confound assessment
- No drug intoxication or poisoning
- Core temperature above 32 C (90 F)

Front 12

what are 3 findings that suggest brain dead pt?

Back 12

- pt is COMATOSE: no cerebral motor response to pain
- ABSENT BRAINSTEM REFLEXES
- APNEA TEST: disconnect from ventilator 8 min and show that pt has no spontaneous respiratory movements

Front 13

name some brainstem reflex tests you would do to check fxn.

Back 13

no pupillary light resp
no ocular motility
no corneal reflex
no jaw jerk reflex
no gag reflex

Front 14

what are 2 confirmatory tests that you can do to show brain death (tho not legally required)?

Back 14

1) EEG showing "flat" at max sensitivity
2) absence of cerebral blood flow (since flow doesn't go to dead cerebral tissue) ==> most common

Front 15

define "persistent vegetative state." when can PVS be judged to be permanent?

Back 15

when a pt is brain dead (not responsive, not conscious) and in a coma for MORE THAN 1 MONTH!!
(even if eyes move due to vestibular system, doesn't mean they can respond to environment in a meaningful way)

- can be judged permanent 12 AFTER TRAUMATIC INJURY
- can be judged permanent 3 months AFTER NONTRAUMATIC INJURY
(chance for recovery after these periods is extremeelllllyyy low)

Front 16

What is the "locked-in syndrome"

Back 16

brainstem damage to motore/sensory pathways with preservation of reticular formation

(bascially knocking out brain stem - medial lemniscus, STT, CST - without touching the RAS. YOU ARE AWAKE AND CONSCIOUS BUT CAN'T FEEL ANYTHING, CAN'T MOVE.

"A LIVING CORPSE"