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What is consciousness?
Awareness of self and environment
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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
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What are the characteristics of an alert patient?
patient is awake and responds to questioning
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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
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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
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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
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What fall under the differential diagnosis of a coma?
- locked in state
- persistent vegitative state
- catatonia
- abulia
- akinetic mutism
- psuedocoma
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Locked-in State
Cause
Presentation
- cause: infarction of the ventral pons due to thrombosis of the basilar artery
- presentation: paralysis of all 4 extremities and lower cranial nerves, therefore vertical eye movements and eye-lid blinking are the only way to communicate
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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
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Catatonia
presentations
risk factors
tx
- presentations: unresponsive and will ignore external stimuli; "waxy flexability" (catelepsy) and echolalia (repitition of words); may not blink to threat
- risk factors: Bi-Polar disorder, PTSD, catatonic schizophrenia
- tx: benzodiazepines or anti-pyschotics
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Abulia
- 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
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Akinetic Mutism
presentations
cause
- presentations: silent, alert-looking immobility, sleep-wake cycles have returned, but no evidence for mental activity
- cause: bilateral destruction of cerebral cortex, hydrocephalus, bilateral BG lesions, paramedian lesion in the reticular formation in the midbrain
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Psuedocoma
- 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
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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
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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
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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
- respiratory pattern
- pupil size and reactivity
- ocular motility (occular motor reflexes)
- motor system
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Glasgow Coma Scale
- low points are bad, high points good
- broken down into eye (4), verbal (5), motor (6)
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If a patient presents with ataxic breathing or slow, regularly breathing where is the damage to this patient?
Medulla
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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
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If a patient presents with psuedobulbar paralysis of voluntary control, where does their lesion lie?
Pontine Base
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If a patient has hyperventilation, then where is their lesion at?
midbrain-rostral pons tegmentum
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What are the characteristics of forebrain damage?
- psuedobulbar laughing or crying
- Cheyne-Stokes respiration (oscillation of apnea and tachypnea)
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If a pupil size is small and reactive, what is the DX?
metabolic problem and/or diencephalic lesion
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If the pupils are dialated, fixed and present unilaterally, what is the DX?
CN III compression
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Patients that have pupils that are midposition and fixed likely have what?
A lesion in the midbrain
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Pinpoint pupils usually indicates a lesion where?
Pons
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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/sleepthis tests the integrity of the sympathetic pathways
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If a patient can blink, what does this indicate?
that the pontine reticular formation is intact
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Oculocephalic Reflex
- 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
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Caloric Stimulation
- Test lateral eyemovents by placing cold water in ear canal and watching eyes deviate that way
- Non-normal response would be no movement
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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
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What are the 5 criteria for brain death?
- Coma
- 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)
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What is the apnea test?
Observing the patient's ability to breath and maintain oxygen levels w/o ventillator
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What are supportive tests to help declare brain death?
- EEG
- Nuclear Perfusion
- Cerebral Angiography
- Transcranial Doppler
- Intracranial pressure monitering
- Evoked potential monitering
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