Disorders of consciousness include coma, vegetative state, minimally conscious state, and locked-in syndrome. Coma is characterized by unarousable unresponsiveness, while the vegetative state involves spontaneous eye opening without purposeful responses. The minimally conscious state involves limited but meaningful responses. Locked-in syndrome involves quadriplegia with preserved consciousness. Evaluation of coma involves stabilization, history, exam including Glasgow Coma Scale, and testing of cranial nerves and motor/sensory function. Brain death criteria require demonstrating lack of brainstem and cortical function over an observation period.

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

3. ConsciousnessConsciousness
Localization

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

17. Sub-Falcine HerniationSub-Falcine 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

39. Decorticate PosturingDecorticate Posturing

40. Decerebrate PosturingDecerebrate Posturing

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)

46. That’s All FolksThat’s All Folks