374.2 🩺 國考版

374.2.1 高頻考點

374.2.1.1 Glasgow Coma Scale

  • E (1-4) + V (1-5) + M (1-6) = 3-15
  • GCS ≀ 8: consider intubation

374.2.1.2 Two Anatomic Causes

  • Bilateral hemispheric (toxic-metabolic >> structural)
  • Brainstem RAS

374.2.1.3 Locked-In Syndrome

  • Ventral pontine lesion (often basilar artery occlusion)
  • Quadriplegic, anarthric
  • Preserved vertical eye movements + blinking
  • Awareness intact

374.2.1.4 Vegetative State

  • Eyes open
  • Sleep-wake
  • No awareness
  • Permanent > 3 mo non-traumatic, 12 mo traumatic

374.2.1.5 Minimally Conscious State

  • Some signs of awareness
  • Inconsistent
  • Better prognosis than VS

374.2.1.6 Pupil Findings

Finding Cause
Bilateral pinpoint reactive Pontine hemorrhage, opioid, organophosphate
Mid-position fixed Midbrain
Bilateral fixed dilated Anoxia, atropine, brain death, late herniation
Unilateral dilated fixed Uncal herniation (CN III compression), PCA aneurysm

374.2.1.7 Motor Posturing

  • Decorticate (flexor): above red nucleus
  • Decerebrate (extensor): below red nucleus — worse
  • Worse: decerebrate > decorticate > no response

374.2.1.8 Breathing Patterns

  • Cheyne-Stokes: cerebral, HF
  • Central neurogenic hyperventilation: midbrain
  • Apneustic: lower pons
  • Ataxic: medulla — pre-arrest

374.2.1.9 Empiric Therapy in Coma

  • Thiamine 100 mg IV (before glucose!)
  • Glucose D50W if low/unmeasured
  • Naloxone if opioid

374.2.1.10 Wernicke Encephalopathy

  • Triad: ophthalmoplegia + confusion + ataxia
  • Thiamine deficiency
  • IV thiamine BEFORE glucose
  • Risk: alcoholism, malnutrition, hyperemesis, bariatric

374.2.1.11 Hepatic Encephalopathy

  • Asterixis
  • Hyperammonemia (variable)
  • Triphasic waves EEG
  • Lactulose + rifaximin

374.2.1.12 Hypoglycemia

  • Focal deficits possible
  • D50W
  • Workup with insulin, C-peptide

374.2.1.13 Opioid OD

  • Pinpoint pupils + hypoventilation + coma
  • Naloxone

374.2.1.14 CO2 Narcosis

  • COPD + O2
  • BiPAP

374.2.1.15 Post-Anoxic Coma

  • Prognosis after 72 hr off sedation, normothermic
  • NSE, EEG, MRI

374.2.2 Brain Herniation Syndromes

374.2.2.1 Uncal (Transtentorial)

  • Medial temporal lobe
  • CN III compression — unilateral fixed dilated pupil
  • Contralateral hemiparesis (then ipsilateral if Kernohan’s notch)
  • Decerebrate posturing

374.2.2.2 Central

  • Bilateral hemispheric
  • Progressive: alert → drowsy → diencephalic → midbrain → medullary
  • Mortal if untreated

374.2.2.3 Tonsillar

  • Cerebellar tonsils through foramen magnum
  • Apnea
  • Sudden death

374.2.2.4 Subfalcine

  • Cingulate under falx
  • ACA compression
  • Leg weakness contralateral