disorders of consciousness
TRANSCRIPT
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Disorders of ConsciousnessDisorders of ConsciousnessStephen Deputy, MD, FAAPStephen Deputy, MD, FAAP
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ConsciousnessConsciousness
• Refers to the awareness of self and environment
• Content of Consciousness• Arousal
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ConsciousnessConsciousnessLocalization
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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
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Depressed Levels of ConsciousnessDepressed Levels of Consciousness
• Lethargy• Stupor• Sleepy Appearing• Somnolence• Obtundation• Coma
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COMACOMA
Unarousable Unresponsiveness• Consciousness: None• Eyes: Do not open to any stimulus• Vocalization: None• Motor: No purposeful movements
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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
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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
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Minimally Conscious StateMinimally Conscious State
Severely altered consciousness but with definite behavioral evidence of awareness
of self and environment
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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
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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
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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
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Causes of ComaCauses of Coma
• Supratentorial Lesions (affecting Bilateral Cerebral Hemispheres/Thalamic Nuclei)
• Infratentorial Lesions (Affecting the Brainstem Reticular Activating System)
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Causes of ComaCauses of Coma
• Toxic/Metabolic Disorders• Infectious/Post-Infectious • Trauma• Seizure/Post-Ictal State• Neoplastic/Paraneoplastic• Structural• Vascular
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Herniation SyndromesHerniation Syndromes
• Subfalcine Herniation• Uncal Herniation• Central Herniation• Cerebellar Tonsillar Herniation
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Regions of Brain HerniationRegions of Brain Herniation
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Sub-Falcine HerniationSub-Falcine Herniation
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Notching of the UncusNotching of the UncusDue to Transtentorial (Uncal) HerniationDue to Transtentorial (Uncal) Herniation
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Downward Cerebellar Tonsillar Herniation Downward Cerebellar Tonsillar Herniation through the Foamen Magnumthrough the Foamen Magnum
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Duret Hemorrhages of the PonsDuret Hemorrhages of the PonsFrom Brainstem HerniationFrom Brainstem Herniation
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CT BrainCT Brain Subdural Hematoma Subdural Hematoma
Subfalcine and Transtentorial HerniationSubfalcine and Transtentorial Herniation
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CT Brain CT Brain Intraventricular Hemorrhage,Intraventricular Hemorrhage,
Hydrocephalus, and Central HerniationHydrocephalus, and Central Herniation
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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)
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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
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Evaluation of ComaEvaluation of Coma
Neurological Examination• Mental Status• Cranial Nerves• Motor Examination• Sensory Examination
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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
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Glasgow Coma ScaleGlasgow Coma ScaleEye Opening
Spontaneous 4To Verbal Command 3To Pain 2None 1
Obeys Commands 6Localizes Pain 5Withdraws to Pain 4Decorticate Postures 3Decrebrate Postures 2None 1
Oriented and Converses 5Confused Conversation 4Inappropriate Words 3Incomprehensible Sounds 2None 1
Motor Response
Verbal Response
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Glasgow Coma ScaleGlasgow Coma Scale(For Infants)(For Infants)
Spontaneous 4To Speech 3To Pain 2None 1
Eye Opening
Normal Spontaneous Movements
6
Withdraws to Touch 5Withdraws to Pain 4Abnormal Flexion 3Abnormal Extension 2None 1
Motor Response
Coos Babbles 5Irritable 4Cries to Pain 3Moans to Pain 2None 1
Verbal Response
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Cranial NervesCranial Nerves
II (optic Nerve)
• Fundoscopic Exam• Pupillary Light Reflex
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Pupils Size Based on LocalizationPupils Size Based on Localization
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Cranial NervesCranial Nerves
III, IV, VI (EOM’s)• Doll’s Eyes Maneuver• Cold Calorics
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Oculocephalic ReflexOculocephalic Reflex(Doll’s Eyes and Cold Calorics)(Doll’s Eyes and Cold Calorics)
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Cranial NervesCranial Nerves
V and VII(Trigeminal and Facial Nerve)
Corneal Blink Reflex• V-1 Afferent• VII Efferent
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Cranial NervesCranial Nerves
IX and XThe Gag Reflex
• IX is Afferent• X is Efferent
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Cranial NervesCranial Nerves
Respiration• Respiratory Patterns Based on Localization• The Apnea Test
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Breathing Patterns Based on Level of Breathing Patterns Based on Level of Brainstem DysfunctionBrainstem Dysfunction
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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
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Motor ExaminationMotor Examination
Spontaneous MovementResponse to Noxious Painful Stimuli
• Localizes Pain• Withdraws from Pain• Decorticate Posture• Decerebrate Posture• No Movement
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Decorticate PosturingDecorticate Posturing
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Decerebrate PosturingDecerebrate Posturing
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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
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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
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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”
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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)
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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)
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That’s All FolksThat’s All Folks