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35 Cards in this Set
- Front
- Back
What are the two integrated functions of consciousness and there associated neuroanatomic locations?
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- 1. Arousal:
o Brainstem Ascending reticular activating system (ARAS) - 2. Cognition: o Cerebral cortex |
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Where anatomically is the ARAS?
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- Begins in the paramedian gray matter bellow ventricular system and extends from posterior hypothalamic reticular formation to approximately the lower third of the pontine tegmentum
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How does coma result pathophysiologically?
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1. Brainstem dysfunction (may be focal), or
2. Diffuse bilaterally hemispheric dysfunction |
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Define coma.
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- (Broad) Any depression of the level of consciousness
- (Narrow) Complete failure of arousal system with no spontaneous eye opening or GCS<8 |
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Define vegetative state.
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- Complete absence of behavioural evidence for self or environmental awareness
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Define minimally conscious state.
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- Altered mental status, but with the ability to follow simple commands, verbalize yes/no responses (regardless of accuracy), or show purposeful behaviour
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Define clouding of consciousness.
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- Disturbance characterized by impaired ability to think clearly and to perceive, respond to, and remember stimuli
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Define confusion.
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- Alterations in higher cerebral functions, such as memory, awareness, and attention
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Define delirium.
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- Disturbed consciousness with motor restlessness, transient hallucinations, disorientation, and hallucinations
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Define obtundation.
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- Patients are awake, but not alert and exhibit psychomotor retardation
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Define stupor.
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- The patient, although conscious, exhibits little or no spontaneous activity. (patients will awaken with stimuli but have little motor or verbal activity when aroused)
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How is the Glasgow Coma Scale scored?
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ye response (E)[edit]
There are four grades starting with the most severe: No eye opening Eye opening in response to pain stimulus. (a peripheral pain stimulus, such as squeezing the lunula area of the patient's fingernail is more effective than a central stimulus such as a trapezius squeeze, due to a grimacing effect).[1] Eye opening to speech. (Not to be confused with the awakening of a sleeping person; such patients receive a score of 4, not 3.) Eyes opening spontaneously Verbal response (V)[edit] There are five grades starting with the most severe: No verbal response Incomprehensible sounds. (Moaning but no words.) Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange) Confused. (The patient responds to questions coherently but there is some disorientation and confusion.) Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.) Motor response (M)[ |
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What are treatable causes of altered mental status (use pneumonic AEIOU-TIPS)?
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* non-convulsive status epilepticus,
* various toxins SANTAs * CO * toxic alcohols * sedative/hypnotic withdrawal * ASA tox - ARDS,tinitus - pseudo sepsis/pneumonia * NMS DAYS * antipsychotic - rigidity LFTS,Pyrexia * Serotonin syndrome HOURS * SSRI,cough syrup,cocaine, * Sx - hypertehrmia,tachycardia,diaphoresis,clonus,rigidity,rigidity,hyperreflexia * DDX * NMS * anticholinergic * malignant hyperthermia * sypathomimetic tox * meningitis * encephalitis |
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Proved an organized extensive differential diagnosis of coma?
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Proved an organized extensive differential diagnosis of coma?
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What constitutes an initial rapid neurologic assessment in comatose patients?
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- Responsiveness
- Pupillary reactivity to light - Movement of extremities |
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What is triple flexion withdrawal of the lower extremities?
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- Flexion of the hip knee and ankle (a spinal cord reflex, implies nothing about the status of the brainstem or cortex)
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What are the major brainstem reflexes used in assessing coma and the neuronal structures they test in particular?
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- Pupillary Light
o IN:2 o OUT:3 - Corneal Blink o IN:5 o OUT:7 - Doll’s eyes o IN 8; MLF+/-cortex o OUT: III, VI * cortex - responsible for awake and aware - bilateral dysfunction - likley systemic * midbrain - 3,4,1,2 check for function - pupil reflex 2 in three out * pons - 5,6,7,8 - corneal reflex 5 in 7 out , dolls eye/caloric interaction 8 and 3,4,6 * medulla - 9,10,11,12 - gag * primitive part of this - breathing response |
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What does resting dysconjugate gaze in the horizontal plane imply when assessing coma?
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- Normal drowsiness
- Various sedated states i.e. Alcohol * Parallel ocular axis should re-emerge with rousing |
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What does vertical dysconjugate gaze imply (skew deviation)?
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- Pontine or cerebellar lesions
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What does sustained downward conjugate gaze imply?
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- Occurs in a variety of neuroligic disorders and is nonlocalizing
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What does sustained upward conjugate gaze imply?
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- Hypoxic encephalopathy
- Intact brainstem |
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What does a persistently adducted eye indicate?
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- CN VI paresis
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What does a persistently abducted eye indicate?
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- CN III paresis
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What is implied by full, slow left-right conjugate roving movements imply?
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- Excludes the midbrain and pons as locations for the cause of coma
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What does ocular bobbing (brisk conjugate caudal jerks followed by slow return to midposition) imply?
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- Classic for bilateral pontine infarcts
- Many metabolic derangements - Brainstem compression by cerebellar hemorrhage |
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What does ocular dipping (slow, cyclic, conjugate downward movement of eyes with rapid return to midposition imply)?
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- Diffuse cortical axonic damage
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What is the strict contraindication to occulocephalic movements (dolls eyes)?
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c-spine
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Caloric testing and dolls eyes - explain results and lesion location
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COWS - cold fast beat away from, warm fast beat towards
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What is the dose of flumazenil?
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who cares!
- 0.2mg IV q 1 min to response (max 1.0mg) |
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What is the treatment of possible Wernike’s encephalopathy?
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- Thiamine 100mg IV
OPTHALMOPLEGIA,GAIT,ALTERED wobbly wacky wonky eyes |
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What clinical characteristics are consistent with myexedema coma?
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- Skin changes
- Mild hypothermia - Bradycardia - Pseudotonic stretch reflexs (delayed relaxation phase) - Hyponatremia |
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What is the treatment of presumed myexedema coma?
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- Steroids (for concurrent adrenal insufficiency – Schmidt syndrome)
- IV Thyroxin |
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What coma patients get antibiotics?
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everyone with unknown aetiology
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Give an algorithm for the diagnostic approach to the patient in coma.
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