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Disorders of ConsciousnessDisorders of Consciousness
Stephen Deputy, MD, FAAPStephen Deputy, MD, FAAP
ConsciousnessConsciousness
• Refers to the awareness of self and
environment
• Content of Consciousness
• Arousal
ConsciousnessConsciousness
Localization
DeleriumDelerium
• Clinical Signs: Agitation, confusion, poor
concentration and orientation, misperception of
sensory stimuli, visual or tactile hallucinations
• Alertness intact but disturbed content of
consciousness
• Generalized or multifocal process
affecting both cerebral hemispheres
Depressed Levels of ConsciousnessDepressed Levels of Consciousness
• Lethargy
• Stupor
• Sleepy Appearing
• Somnolence
• Obtundation
• Coma
COMACOMA
Unarousable Unresponsiveness
• Consciousness: None
• Eyes: Do not open to any stimulus
• Vocalization: None
• Motor: No purposeful movements
COMACOMA
All patients in a coma will change after
2 to 4 weeks
• Improve to a higher level of alertness
• Expire
• Evolve into a vegetative state
Vegetative StateVegetative State
Patients who have survived coma without gaining
higher cognitive function
• Consciousness: None
• Eyes: Spontaneous eye opening and closure
• Vocalization: Groans and Grunts, no formed words or
purposeful communication
• Motor: Postures or withdraws to noxious stimulus,
occasional nonpurposeful movement
• EEG: Preserved sleep and wake cycles
Minimally Conscious StateMinimally Conscious State
Severely altered consciousness but with
definite behavioral evidence of awareness
of self and environment
Minimally Conscious StateMinimally Conscious State
• Follows simple commands
• Gestural or verbal “yes/no” responses
• Intelligible verbalization
• Movements and affective behaviors occur
in contingent relation to relevant
environment stimuli and not attributable to
reflexive activity
Locked-In SyndromeLocked-In Syndrome
• Loss of voluntary motor control and
vocalizations with preserved
consciousness
• Bilateral injury to the cortic-spinal and
cortical-bulbar tracts
• Pontine hemorrhage, tumor,
demyelination
Locked-In SyndromeLocked-In Syndrome
• Consciousness: Preserved
• Eyes: No lateral movements, blink and vertical
eye movements preserved, vision intact
• Vocalizations: Aphonic/Anarthric
• Motor: Quadriplegic
• EEG: Normal awake background
Causes of ComaCauses of Coma
• Supratentorial Lesions (affecting Bilateral
Cerebral Hemispheres/Thalamic Nuclei)
• Infratentorial Lesions (Affecting the
Brainstem Reticular Activating System)
Causes of ComaCauses of Coma
• Toxic/Metabolic Disorders
• Infectious/Post-Infectious
• Trauma
• Seizure/Post-Ictal State
• Neoplastic/Paraneoplastic
• Structural
• Vascular
Herniation SyndromesHerniation Syndromes
• Subfalcine Herniation
• Uncal Herniation
• Central Herniation
• Cerebellar Tonsillar Herniation
Regions of Brain HerniationRegions of Brain Herniation
Sub-Falcine HerniationSub-Falcine Herniation
Notching of the UncusNotching of the Uncus
Due to Transtentorial (Uncal) HerniationDue to Transtentorial (Uncal) Herniation
Downward Cerebellar Tonsillar HerniationDownward Cerebellar Tonsillar Herniation
through the Foamen Magnumthrough the Foamen Magnum
Duret Hemorrhages of the PonsDuret Hemorrhages of the Pons
From Brainstem HerniationFrom Brainstem Herniation
CT BrainCT Brain
Subdural HematomaSubdural Hematoma
Subfalcine and Transtentorial HerniationSubfalcine and Transtentorial Herniation
CT BrainCT Brain
Intraventricular Hemorrhage,Intraventricular Hemorrhage,
Hydrocephalus, and Central HerniationHydrocephalus, and Central Herniation
Evaluation of ComaEvaluation of Coma
Patient Stabilization (ABCD’s)
History
• Duration and Onset of Coma
• Trauma
• Past Medical History
• Medications (Perscribed, OTC, Illicit, Accessable)
• Family History (Others affected)
Evaluation of ComaEvaluation of Coma
Physical Examination
• HEENT: Head size/Ant Fontanelle.
Nuchal rigidity. Signs of trauma.
C/Spine Precautions
• Heart/Lung/Abdomen/Extremities:
Look for evidence of other organ
failure/Injury
Evaluation of ComaEvaluation of Coma
Neurological Examination
• Mental Status
• Cranial Nerves
• Motor Examination
• Sensory Examination
Evaluation of ComaEvaluation of Coma
Mental Status
• Describe what you see
• Best Eye Opening, Vocalization, and
Motor Response to various Forms of
Stimuli
• Glasgow Coma Score
Glasgow Coma ScaleGlasgow Coma Scale
Eye Opening
Spontaneous 4
To Verbal Command 3
To Pain 2
None 1
Obeys Commands 6
Localizes Pain 5
Withdraws to Pain 4
Decorticate Postures 3
Decrebrate Postures 2
None 1
Oriented and Converses 5
Confused Conversation 4
Inappropriate Words 3
Incomprehensible Sounds 2
None 1
Motor Response
Verbal Response
Glasgow Coma ScaleGlasgow Coma Scale
(For Infants)(For Infants)
Spontaneous 4
To Speech 3
To Pain 2
None 1
Eye Opening
Normal Spontaneous
Movements
6
Withdraws to Touch 5
Withdraws to Pain 4
Abnormal Flexion 3
Abnormal Extension 2
None 1
Motor Response
Coos Babbles 5
Irritable 4
Cries to Pain 3
Moans to Pain 2
None 1
Verbal Response
Cranial NervesCranial Nerves
II (optic Nerve)
• Fundoscopic Exam
• Pupillary Light Reflex
Pupils Size Based on LocalizationPupils Size Based on Localization
Cranial NervesCranial Nerves
III, IV, VI (EOM’s)
• Doll’s Eyes Maneuver
• Cold Calorics
Oculocephalic ReflexOculocephalic Reflex
(Doll’s Eyes and Cold Calorics)(Doll’s Eyes and Cold Calorics)
Cranial NervesCranial Nerves
V and VII
(Trigeminal and Facial Nerve)
Corneal Blink Reflex
• V-1 Afferent
• VII Efferent
Cranial NervesCranial Nerves
IX and X
The Gag Reflex
• IX is Afferent
• X is Efferent
Cranial NervesCranial Nerves
Respiration
• Respiratory Patterns Based on Localization
• The Apnea Test
Breathing Patterns Based on Level ofBreathing Patterns Based on Level of
Brainstem DysfunctionBrainstem Dysfunction
Cranial NervesCranial Nerves
The Apnea Test
• No CNS Depressants or NMJ Blockade
• Ventilate with 100% FiO2 for 20 minutes
• Disconnect Ventilator and Continue O2
• ABG until PCO2 > 60mmHg
• Watch for any signs of ventilation
Motor ExaminationMotor Examination
Spontaneous Movement
Response to Noxious Painful Stimuli
• Localizes Pain
• Withdraws from Pain
• Decorticate Posture
• Decerebrate Posture
• No Movement
Decorticate PosturingDecorticate Posturing
Decerebrate PosturingDecerebrate Posturing
Motor ExaminationMotor Examination
Deep Tendon Reflexes
• Segmental Spinal Reflex
• Disinhibition of DTR’s When Cortical
Spinal Tract is Dysfunctional
• Triple Flexion Withdrawal and the Babinski
Response
Sensory ExaminationSensory Examination
• Any motor response to painful stimuli on
the right or left side of body?
• Watch for Pulse or Blood Pressure
Elevations with Deep Painful Stimulation
Brain DeathBrain Death
• Accepted as death for medical, legal, and
public opinion standards
• Concept developed at the same time as
organ transplantation
• “Irriversible cessation of all cerebral
activity, including that of the brainstem”
• “Irreversible deep coma and lack of
spontaneous respiration”
Brain Death CriteriaBrain Death Criteria
• Understand the mechanism or illness that
led up to brain death
• Exclude conditions which may influence
examination (Hypothermia, Sedating
Medications/Toxins, Paralytic Agents,
Severe Peripheral Nervous System
Disease)
Brain Death CriteriaBrain Death Criteria
• Determine lack of Cortical Function by
examination
• Determine lack of Brainstem Function by
examination (includes apnea test)
• Observation period (Varies based on age and
whether mechanism of brain death is known)
• Ancillary Testing (Isoelectric EEG, Lack of cerebral
blood flow, Evoked Potentials)
That’s All FolksThat’s All Folks

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Disorders of consciousness

  • 1. Disorders of ConsciousnessDisorders of Consciousness Stephen Deputy, MD, FAAPStephen Deputy, MD, FAAP
  • 2. ConsciousnessConsciousness • Refers to the awareness of self and environment • Content of Consciousness • Arousal
  • 4. DeleriumDelerium • Clinical Signs: Agitation, confusion, poor concentration and orientation, misperception of sensory stimuli, visual or tactile hallucinations • Alertness intact but disturbed content of consciousness • Generalized or multifocal process affecting both cerebral hemispheres
  • 5. Depressed Levels of ConsciousnessDepressed Levels of Consciousness • Lethargy • Stupor • Sleepy Appearing • Somnolence • Obtundation • Coma
  • 6. COMACOMA Unarousable Unresponsiveness • Consciousness: None • Eyes: Do not open to any stimulus • Vocalization: None • Motor: No purposeful movements
  • 7. COMACOMA All patients in a coma will change after 2 to 4 weeks • Improve to a higher level of alertness • Expire • Evolve into a vegetative state
  • 8. Vegetative StateVegetative State Patients who have survived coma without gaining higher cognitive function • Consciousness: None • Eyes: Spontaneous eye opening and closure • Vocalization: Groans and Grunts, no formed words or purposeful communication • Motor: Postures or withdraws to noxious stimulus, occasional nonpurposeful movement • EEG: Preserved sleep and wake cycles
  • 9. Minimally Conscious StateMinimally Conscious State Severely altered consciousness but with definite behavioral evidence of awareness of self and environment
  • 10. Minimally Conscious StateMinimally Conscious State • Follows simple commands • Gestural or verbal “yes/no” responses • Intelligible verbalization • Movements and affective behaviors occur in contingent relation to relevant environment stimuli and not attributable to reflexive activity
  • 11. Locked-In SyndromeLocked-In Syndrome • Loss of voluntary motor control and vocalizations with preserved consciousness • Bilateral injury to the cortic-spinal and cortical-bulbar tracts • Pontine hemorrhage, tumor, demyelination
  • 12. Locked-In SyndromeLocked-In Syndrome • Consciousness: Preserved • Eyes: No lateral movements, blink and vertical eye movements preserved, vision intact • Vocalizations: Aphonic/Anarthric • Motor: Quadriplegic • EEG: Normal awake background
  • 13. Causes of ComaCauses of Coma • Supratentorial Lesions (affecting Bilateral Cerebral Hemispheres/Thalamic Nuclei) • Infratentorial Lesions (Affecting the Brainstem Reticular Activating System)
  • 14. Causes of ComaCauses of Coma • Toxic/Metabolic Disorders • Infectious/Post-Infectious • Trauma • Seizure/Post-Ictal State • Neoplastic/Paraneoplastic • Structural • Vascular
  • 15. Herniation SyndromesHerniation Syndromes • Subfalcine Herniation • Uncal Herniation • Central Herniation • Cerebellar Tonsillar Herniation
  • 16. Regions of Brain HerniationRegions of Brain Herniation
  • 18. Notching of the UncusNotching of the Uncus Due to Transtentorial (Uncal) HerniationDue to Transtentorial (Uncal) Herniation
  • 19. Downward Cerebellar Tonsillar HerniationDownward Cerebellar Tonsillar Herniation through the Foamen Magnumthrough the Foamen Magnum
  • 20. Duret Hemorrhages of the PonsDuret Hemorrhages of the Pons From Brainstem HerniationFrom Brainstem Herniation
  • 21. CT BrainCT Brain Subdural HematomaSubdural Hematoma Subfalcine and Transtentorial HerniationSubfalcine and Transtentorial Herniation
  • 22. CT BrainCT Brain Intraventricular Hemorrhage,Intraventricular Hemorrhage, Hydrocephalus, and Central HerniationHydrocephalus, and Central Herniation
  • 23. Evaluation of ComaEvaluation of Coma Patient Stabilization (ABCD’s) History • Duration and Onset of Coma • Trauma • Past Medical History • Medications (Perscribed, OTC, Illicit, Accessable) • Family History (Others affected)
  • 24. Evaluation of ComaEvaluation of Coma Physical Examination • HEENT: Head size/Ant Fontanelle. Nuchal rigidity. Signs of trauma. C/Spine Precautions • Heart/Lung/Abdomen/Extremities: Look for evidence of other organ failure/Injury
  • 25. Evaluation of ComaEvaluation of Coma Neurological Examination • Mental Status • Cranial Nerves • Motor Examination • Sensory Examination
  • 26. Evaluation of ComaEvaluation of Coma Mental Status • Describe what you see • Best Eye Opening, Vocalization, and Motor Response to various Forms of Stimuli • Glasgow Coma Score
  • 27. Glasgow Coma ScaleGlasgow Coma Scale Eye Opening Spontaneous 4 To Verbal Command 3 To Pain 2 None 1 Obeys Commands 6 Localizes Pain 5 Withdraws to Pain 4 Decorticate Postures 3 Decrebrate Postures 2 None 1 Oriented and Converses 5 Confused Conversation 4 Inappropriate Words 3 Incomprehensible Sounds 2 None 1 Motor Response Verbal Response
  • 28. Glasgow Coma ScaleGlasgow Coma Scale (For Infants)(For Infants) Spontaneous 4 To Speech 3 To Pain 2 None 1 Eye Opening Normal Spontaneous Movements 6 Withdraws to Touch 5 Withdraws to Pain 4 Abnormal Flexion 3 Abnormal Extension 2 None 1 Motor Response Coos Babbles 5 Irritable 4 Cries to Pain 3 Moans to Pain 2 None 1 Verbal Response
  • 29. Cranial NervesCranial Nerves II (optic Nerve) • Fundoscopic Exam • Pupillary Light Reflex
  • 30. Pupils Size Based on LocalizationPupils Size Based on Localization
  • 31. Cranial NervesCranial Nerves III, IV, VI (EOM’s) • Doll’s Eyes Maneuver • Cold Calorics
  • 32. Oculocephalic ReflexOculocephalic Reflex (Doll’s Eyes and Cold Calorics)(Doll’s Eyes and Cold Calorics)
  • 33. Cranial NervesCranial Nerves V and VII (Trigeminal and Facial Nerve) Corneal Blink Reflex • V-1 Afferent • VII Efferent
  • 34. Cranial NervesCranial Nerves IX and X The Gag Reflex • IX is Afferent • X is Efferent
  • 35. Cranial NervesCranial Nerves Respiration • Respiratory Patterns Based on Localization • The Apnea Test
  • 36. Breathing Patterns Based on Level ofBreathing Patterns Based on Level of Brainstem DysfunctionBrainstem Dysfunction
  • 37. Cranial NervesCranial Nerves The Apnea Test • No CNS Depressants or NMJ Blockade • Ventilate with 100% FiO2 for 20 minutes • Disconnect Ventilator and Continue O2 • ABG until PCO2 > 60mmHg • Watch for any signs of ventilation
  • 38. Motor ExaminationMotor Examination Spontaneous Movement Response to Noxious Painful Stimuli • Localizes Pain • Withdraws from Pain • Decorticate Posture • Decerebrate Posture • No Movement
  • 41. Motor ExaminationMotor Examination Deep Tendon Reflexes • Segmental Spinal Reflex • Disinhibition of DTR’s When Cortical Spinal Tract is Dysfunctional • Triple Flexion Withdrawal and the Babinski Response
  • 42. Sensory ExaminationSensory Examination • Any motor response to painful stimuli on the right or left side of body? • Watch for Pulse or Blood Pressure Elevations with Deep Painful Stimulation
  • 43. Brain DeathBrain Death • Accepted as death for medical, legal, and public opinion standards • Concept developed at the same time as organ transplantation • “Irriversible cessation of all cerebral activity, including that of the brainstem” • “Irreversible deep coma and lack of spontaneous respiration”
  • 44. Brain Death CriteriaBrain Death Criteria • Understand the mechanism or illness that led up to brain death • Exclude conditions which may influence examination (Hypothermia, Sedating Medications/Toxins, Paralytic Agents, Severe Peripheral Nervous System Disease)
  • 45. Brain Death CriteriaBrain Death Criteria • Determine lack of Cortical Function by examination • Determine lack of Brainstem Function by examination (includes apnea test) • Observation period (Varies based on age and whether mechanism of brain death is known) • Ancillary Testing (Isoelectric EEG, Lack of cerebral blood flow, Evoked Potentials)