Lecture 59: Stupor, Coma, and Death
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Lecture 59: Stupor, Coma, and Death
Neuroscience Week 5
What is consciousness?
Awareness of self and environment
What is delirium?
state characterized by disoreintation, fear, irritability, mispreception of sensory stimuli, and visual hallucinations
lucid periods can alternate with delirius episodes....so you do not always have to present the symptoms above all the time
What are the characteristics of an alert patient?
patient is awake and responds to questioning
What does a lethargic patient do?
lethargy describes a certain alertness
a lethargic patient is more than sleepy and falls asleep during questioning, but can still be aroused
What does a stuporous patient present as?
patient is unresponsive and must be aroused with vigorous and repeated stimuli
stupor is a degree of alertness much like alert, lethargy, and coma
What does a comatose patient present as?
a patient who is comatose does not respond to anything and "unarousable"
coma is a way to describe a patient's alertness
What fall under the differential diagnosis of a coma?
locked in state
persistent vegitative state
infarction of the ventral pons due to thrombosis of the basilar artery
: paralysis of all 4 extremities and lower cranial nerves, therefore vertical eye movements and eye-lid blinking are the only way to communicate
Persistent Vegetative State
conditions of people who survive severe brain injury without recovering manifestations of higher mental activity
after 1 month of the injury
no awareness of self or environment
inability to interact with others
no evidence of behavioral responses to stimuli
Bowel and bladder incontinence
Brainstem and hypothalamus autonomic functions must be spared
Some cranial nerve reflexes maybe spared
unresponsive and will ignore external stimuli; "waxy flexability" (catelepsy) and echolalia (repitition of words); may not blink to threat
: Bi-Polar disorder, PTSD, catatonic schizophrenia
: benzodiazepines or anti-pyschotics
similar to akinetic mutism
patient has a lack of will
probably a result of cerebral injuries
creates problems with rehab, b/c they don't care/don't want to do it
: silent, alert-looking immobility, sleep-wake cycles have returned, but no evidence for mental activity
: bilateral destruction of cerebral cortex, hydrocephalus, bilateral BG lesions, paramedian lesion in the reticular formation in the midbrain
patient fakes it
but cannot be sustained for more than a few minutes because neurologists are mean people and can shock them and make it very uncomfortable for them
Where must a focal lesion be in a patient who has stupor, coma, or delerium?
In the brainstem
If the lesion is in the cortex, it is generally multifocal or diffuse
What are three ways comas come about?
any supratentorial lesion that compresses or damages ascending reticular activating systems
subtentorial mass that directly damages the brainstem central core
metabolic disorders that affect brain function
What five things should be noted in a neurological examination of a patient who is comatose?
state of consciousness which is evaluated by the glasgow scale
pupil size and reactivity
ocular motility (occular motor reflexes)
Glasgow Coma Scale
low points are bad, high points good
broken down into eye (4), verbal (5), motor (6)
If a patient presents with ataxic breathing or slow, regularly breathing where is the damage to this patient?
If a patient presents with apneustic breathing (gasping followed by normal), cluster breathing, ataxic breathing or slow regular breathing, where is the lesion at?
Lower pontine tegmentum
If a patient presents with psuedobulbar paralysis of voluntary control, where does their lesion lie?
If a patient has hyperventilation, then where is their lesion at?
midbrain-rostral pons tegmentum
What are the characteristics of forebrain damage?
psuedobulbar laughing or crying
(oscillation of apnea and tachypnea)
If a pupil size is small and reactive, what is the DX?
metabolic problem and/or diencephalic lesion
If the pupils are dialated, fixed and present unilaterally, what is the DX?
CN III compression
Patients that have pupils that are midposition and fixed likely have what?
A lesion in the midbrain
Pinpoint pupils usually indicates a lesion where?
What is the ciliospinal reflex and what does it test?
the test consists of pinching the patient and seeing dialation of the pupils
if marked dialation, then more indicative of coma/sleep
this tests the integrity of the sympathetic pathways
If a patient can blink, what does this indicate?
pontine reticular formation
AKA "Doll's Eyes"
Positive response is both eyes deviating opposite of the head turn
then the eyes rapidly return after the head is moved
Test lateral eyemovents by placing cold water in ear canal and watching eyes deviate that way
Non-normal response would be no movement
What would you see in a patient that was comatose that told you they had a poor prognosis?
Absense of Bilateral somatosensory evoked potentials (SSEP) w/1-3 days
>33ug/L of serum neuron-specific enolase w/1-3 days
presence of seizures or myoclonus
Burst Suppression pattern on EEG
What are the 5 criteria for brain death?
No spontaneous respirations
Absent Brain Stem reflexes (cold caloric testing, gag reflex, pupillary responses, facial motor reflexes)
Isoelectric EEG (flat lined)
Abscence of reversable cause (drug overdose, patient is above 32 C)
What is the apnea test?
Observing the patient's ability to breath and maintain oxygen levels w/o ventillator
What are supportive tests to help declare brain death?
Intracranial pressure monitering
Evoked potential monitering