Neurological Examination of an unconscious patient

Posted by e-Medical PPT Thursday, March 10, 2011
Obtundation; responds-to verbal stimuli although slow and inappropriate
Stupor; the subject can be aroused only by vigorous and repeated noxious stimuli
Coma; unarousable and unresponsive

Respiratory pattern
Hyperventilation - midbrain and upper pons lesion
   metabolic diseases e.g. hepatic coma, diabetes and generalised raised intracranial pressure in its early stages.
Hypoventilation - medullary, upper cervical spinal lesion
        Drug overdose and later stages of cerebral herniation.
 Cheyne-Stoke respiration – usually  diencephalic lesion
       central transtentorial herniation and obstructive hydrocephalus.
Ataxic respiration (completely irregular breathing)
            brain-stem dysfunction of a diffuse nature

Pupillary size and reaction
Medium to dilated symmetrical pupils fixed to light - structural disease of the brain stem
Small symmetrical pupils reactive to light - metabolic diseases and drug overdose
Unequal pupil fixed to light  - intracranial mass lesion producing 3rd nerve palsy e.g in unilateral uncal herniation

Eye movements
Vestibulo-ocular reflexes – douching of one ear with cold water produces ipsi-lateral deviation of both eyes with a contralateral quick phase nystagmus lasting for 1—2 minutes. Use of hot water produces the opposite effect i.e. contralateral deviation with ipsilateral quick phase nystagmus. Bilateral douching with cold water gives rise to downward deviation with upward nystagmus and with hot water the opposite response. Absence or abnormal response indicates brain-stem dysfunction.
Oculo-cephalic reflexes (Doll's eye movement ) - Normal response consist of deviation of both eyes to the opposite direction of head rotation. Again absence or abnormal response indicates brain-stem dysfunction.

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