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35 Cards in this Set

  • Front
  • Back
What are the two integrated functions of consciousness and there associated neuroanatomic locations?
- 1. Arousal:
o Brainstem Ascending reticular activating system (ARAS)
- 2. Cognition:
o Cerebral cortex
Where anatomically is the ARAS?
- 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
How does coma result pathophysiologically?
1. Brainstem dysfunction (may be focal), or
2. Diffuse bilaterally hemispheric dysfunction
Define coma.
- (Broad) Any depression of the level of consciousness
- (Narrow) Complete failure of arousal system with no spontaneous eye opening
or GCS<8
Define vegetative state.
- Complete absence of behavioural evidence for self or environmental awareness
Define minimally conscious state.
- Altered mental status, but with the ability to follow simple commands, verbalize yes/no responses (regardless of accuracy), or show purposeful behaviour
Define clouding of consciousness.
- Disturbance characterized by impaired ability to think clearly and to perceive, respond to, and remember stimuli
Define confusion.
- Alterations in higher cerebral functions, such as memory, awareness, and attention
Define delirium.
- Disturbed consciousness with motor restlessness, transient hallucinations, disorientation, and hallucinations
Define obtundation.
- Patients are awake, but not alert and exhibit psychomotor retardation
Define stupor.
- The patient, although conscious, exhibits little or no spontaneous activity. (patients will awaken with stimuli but have little motor or verbal activity when aroused)
How is the Glasgow Coma Scale scored?
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)[
What are treatable causes of altered mental status (use pneumonic AEIOU-TIPS)?
* non-convulsive status epilepticus,
   * various toxins SANTAs

      * CO
      * toxic alcohols
      * sedative/hypnotic withdrawal
      * ASA tox - ARDS,tinitus - pseudo sepsis/pneumonia
      * NMS DAYS

         * antipsychotic - ...
* 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
Proved an organized extensive differential diagnosis of coma?
Proved an organized extensive differential diagnosis of coma?
What constitutes an initial rapid neurologic assessment in comatose patients?
- Responsiveness
- Pupillary reactivity to light
- Movement of extremities
What is triple flexion withdrawal of the lower extremities?
- Flexion of the hip knee and ankle (a spinal cord reflex, implies nothing about the status of the brainstem or cortex)
What are the major brainstem reflexes used in assessing coma and the neuronal structures they test in particular?
-	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 ...
- 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
What does resting dysconjugate gaze in the horizontal plane imply when assessing coma?
- Normal drowsiness
- Various sedated states i.e. Alcohol
* Parallel ocular axis should re-emerge with rousing
What does vertical dysconjugate gaze imply (skew deviation)?
- Pontine or cerebellar lesions
What does sustained downward conjugate gaze imply?
- Occurs in a variety of neuroligic disorders and is nonlocalizing
What does sustained upward conjugate gaze imply?
- Hypoxic encephalopathy
- Intact brainstem
What does a persistently adducted eye indicate?
- CN VI paresis
What does a persistently abducted eye indicate?
- CN III paresis
What is implied by full, slow left-right conjugate roving movements imply?
- Excludes the midbrain and pons as locations for the cause of coma
What does ocular bobbing (brisk conjugate caudal jerks followed by slow return to midposition) imply?
- Classic for bilateral pontine infarcts
- Many metabolic derangements
- Brainstem compression by cerebellar hemorrhage
What does ocular dipping (slow, cyclic, conjugate downward movement of eyes with rapid return to midposition imply)?
- Diffuse cortical axonic damage
What is the strict contraindication to occulocephalic movements (dolls eyes)?
c-spine
Caloric testing and dolls eyes - explain results and lesion location
COWS - cold fast beat away from, warm fast beat towards
COWS - cold fast beat away from, warm fast beat towards
What is the dose of flumazenil?
who cares!

- 0.2mg IV q 1 min to response (max 1.0mg)
What is the treatment of possible Wernike’s encephalopathy?
- Thiamine 100mg IV

OPTHALMOPLEGIA,GAIT,ALTERED wobbly wacky wonky eyes
What clinical characteristics are consistent with myexedema coma?
- Skin changes
- Mild hypothermia
- Bradycardia
- Pseudotonic stretch reflexs (delayed relaxation phase)
- Hyponatremia
What is the treatment of presumed myexedema coma?
- Steroids (for concurrent adrenal insufficiency – Schmidt syndrome)
- IV Thyroxin
What coma patients get antibiotics?
everyone with unknown aetiology
Give an algorithm for the diagnostic approach to the patient in coma.