The unconscious

patient
 Definition
Consciousness is the state of awareness of the
self and environment
Coma is the total absence of awareness of self
and the environment even when the patient is
externally stimulated.
Components of conscious behaviour
Arousal state of wakefulness
Content of consciousness sum of cognitive
and affective mental functions
 state of wakefulness
Arousal Content
- Ascending Reticular
Activating System
(ARAS) core of the - Cerebral hemispheres
brainstem
- receives input from
numerous somatic
afferents
- projects to midline
thalamic nuclei (which
are in a circuit with
cortical structures) and
the limbic system
 ARAS
ARAS acts as a gating system, increasing or
decreasing thalamic inhibitory influence on the
cortex
alters effect of sensory stimuli ascending
alters descending cortical stimulation
 In other words
Coma implies dysfunction of:
ARAS or
Both hemi-cortices

Anatomically, this means

central brainstem structures (bilaterally) from pons
to rostral midbrain
both hemispheres
 Classification
Supratentorial lesions cause coma by either
widespread bilateral disease, increased intracranial
pressure, or herniation.
Infratentorial lesions involve the RAS, usually with
associated brainstem signs
Metabolic coma causes diffuse hemispheric
involvement and depression of RAS, usually without
focal findings
Psychogenic
 The spectrum
State Description of Patient

Lethargy fatigued with minimal difficulty

maintaining alertness

Obtunded moderate reduction in alertness with

decreased interest in environment,
responsive to stimuli other than pain

Stupor unresponsiveness with arousal only

to vigorous/painful stimulus, return to
unresponsiveness with removal of
stimulus

Lacks specificity..
 Teasdale and Jennet [Lancet 1974]

Eye opening
Verbal score
Motor score
Best score 15/15
Worst score 3/15
 Eye opening
1 does not open eyes
2 opens eyes to painful stimulus
3 opens eyes to verbal command
4 opens eyes spontaneously
 Verbal response
1 no verbal response
2 incomprehensible sounds
3 inappropriate words
4 confused
5 oriented
 Motor response
1 no motor response
2 extends to painful stimulus
3 decorticate posturing painful stimulus
4 withdraws to painful stimulus
5 localises painful stimulus
6 obeys commands
 Glasgow Coma Score
Eye opening Best Motor Response
4 - spontaneous 6 - obeys
3 - to speech 5 - localizes
2 - to pain 4 - withdraws
1 - none
3 - abnormal flexion
Verbal Response 2 - abnormal extension
5 - oriented 1 - none
4 - confused
conversation
3 - inappropriate words
2 - incomprehensible
sounds
1 - none
 Children's coma scale
( <4yrs)

Points Best eye opening Best verbal response Best motor response

6 obeys

5 Smiles, oriented to Localizes pain

sound, follows
objects, interacts
4 Spontaneous Consolable cry Withdraws to pain

3 To call Inconsistently flexion

inconsolable
2 To pain Inconsolable extensor

1 None No response No response

 ADVANTAGES DISADVANTAGES
*objectivity *ceiling effects
*reproducibility *orbital injury, intubated
*simplicity patients
 Primary objectives
Airway
Breathing
Circulation
Treatment of rapidly progressive, dangerous metabolic
causes of coma (hypoglycemia)
Evaluation as to whether there is significant increased
ICP or mass lesions.
Treatment of ICP to temporize until surgical
intervention is possible.
 History
Source
Mode of onset, duration temporal profile
Preceding incidents trauma, headache, seizure,
Preceding illnesses diabetes, hypertension,
cerebrovascular, cardiac, hepatic, renal,
endocrine, hematological, tumor, ear infection,
substance abuse.
 General examination
Fever meningitis, septicemia, SAH
Pallor, Icterus, Cyanosis, Edema
Dehydration, Cachexia
Petechiae blood dyscrasia, bacterial endocarditis,
meningiococcemia
Edema cardiac, renal
Smell alcohol, acetone, fetor hepaticus
Bruises, Battles sign, periorbital ecchymosis
Signs of meningeal irritation
 General examination
Pulse bradycardia
Blood pressure low in shock, high with raised
ICP
 Cushings triad

Bradycardia
Due to ischemia or pressure on the brainstem
Hypertension
Respiratory changes
Cheyne-Stokes breathing
Sustained hyperventilation

Rapid and shallow respiration

 Respiration
Central neurogenic hyperventillation lesions in the
perimedian reticular formation of low midbrain,
upper pons
Apneustic, cluster, Ataxic (Lower pons)

Loss of automatic breathing (medulla)

Cheyne-Stokes bilateral hemisphere lesions, raised

intracranial pressure
Kussmaul diabetic ketoacidosis
 Neurological examination
GCS
Mental examination failure of attention,
hallucinations, memory deficits
 Cranial nerves
Pupillary light response (CN 2-3)
Occulocephalic/calorics (CN 3,4,6,8)

Corneal reflex (CN 5,7)

Gag reflex (CN 9,10)

 II nerve
Light response direct and cnsensual
Fundus papilledema
 The pupillary response
Afferent Limb: Optic Nerve
Efferent Limb: Parasympathetics via
occulomotor
Midbrain integrity/ tectum
Uncal Herniation (3rd nerve dysfunction)
 Watch out!
Traumatic mydriasis
Drugs atropine other mydriatics

Mention
- Side
- Size
- reaction
 Pupils with localising value
Unilateral dilation - 3rd nerve lesion
Bilateral fixed dilated Midbrain - Large fixed
pupils unresponsive to light, hippus
Pinpoint pupils pons - symp. dysfunction plus
parasymp.irritation
 Pupils in metabolic coma
Usually equal and reactive
Hence a sign for distinguishing metabolic from
structural coma

EXCEPTIONS
- Fixed dilated pupils glutethimide toxicity,
atropine, rarely botulinum toxicity, anoxic
encephalopathy
- Miosis narcotics - morphine
 Corneal reflex
Afferent: Trigeminal Nerve
Efferent: Third Nerve (Bells Phenomenon

and Facial Nerve (Eye closure)

Tests dorsal midbrain (Bells) and pontine
integrity (Eye closure)
 Eye deviations
Conjugate Deviation suggests
- Frontal looks to the side of the lesion

- pontine damage looks away from the side of the

lesion
- Mid brain pretectal downward deviation

Dysconjugate eye movements suggests

Cranial nerve abnormality
- III nerve

- IV nerve
Abnormal eye movements
Roving coma with intact brain stem
Bobbing severe destructive caudal pontine
lesions
Retractory and convergence nystagmus
mesencephalic lesion
 Occulocephalics, caloric
Same reflex elicited differently
Afferent: Eighth nerve
Efferent: 3,4,6 via MLF and PPRF
Occulocephalics may also involve proprioceptive
afferents from the neck
 Continued
Calorics normal response cows
Dolls eye check cervical spine for stability
before doing the test
Oculocephalic and Vestibular Responses
 The IX and X
Gag reflex Cough reflex
Afferent: Afferent: vagus
Glossopharyngeal Efferent: vagus
Efferent: Vagus
 Motor system
Paucity of spontaneous movements
Asymmetry of motor response to pain
Flaccidity, loss of tone
Abnormal movments seizures, tremors,
choreiform movements, flaps
 Sensory system
Response to pain
In the presence of hemiparesis?
 Reflexes
Brainstem
Deep tendon
Biceps, brachioradialis, triceps
Patellar, Achilles

Plantar Responses
Superficial skin
Abdominal, cremasteric, anal
 Differential diagnosis
Trauma
Cerebrovascular disease
Intoxications
Infection
Metabolic disturbance
 Mimics
Akinetic mutism
Locked-in syndrome
Catatonia
Conversion reactions
 Akinetic mutism
Silent, immobile but alert appearing
Usually due to lesion in bilateral mesial frontal
lobes, bilateral thalamic lesions or lesions in peri-
aqueductal grey (brainstem)
 Locked in syndrome
Infarction of basis pontis (all descending motor
fibers to body and face)
May spare eye-movements
Often spares eye-opening
EEG is normal or shows alpha activity
 Catatonia
Symptom complex associated with severe
psychiatric disease with:
stupor, excitement, mutism, posturing
can also be seen in organic brain diease: encephalitis,
toxic and drug-induced psychosis
 Conversion reactions
Fairly rare
Occulocephalics may or may not be present
The presence of nystagmus with cold water
calorics indicates the patient is physiologically
awake
EEG used to confirm normal activity
 ABC
Airway
Breathing
Circulation
Blood tests electrolytes, glucose, BUN, counts,
ABG
Specific tests calcium, ammonia,
anticonvulsant levels, tox-screen
Specific medications glucose, naloxone,
thiamine
 Supratentorial Mass Lesions
Hematoma
Neoplasm
Abscess
Contusion
Vascular Accidents
Diffuse Axonal Damage
Supratentorial Mass Lesions
Acute epidural hematoma and midline shift
Supratentorial Mass Lesions
Subdural Hematoma
Supratentorial Mass Lesions
Cerebral Abscess
 Supratentorial Mass Lesions
Altered consciousness is based on
Increased intracranial pressure
Herniation

Diffuse bilateral lesions

Herniation syndromes
 Type Structure Clinical features
shifted Artery occluded
Central trans Diancephalon thro tent Central Chronic / Uncal Acute Brain
tentorial hiatus stem compression
Altered consciousness
Uncal Uncus & 3rdN palsy, homonymous hemianopia,
parahippocampal gyrus contalateral weakness.
thro tent hiatus PCA
Cingulate Cingulate gyrus under Asymptomatic till ACA is kinked
falx producing contralateral weakness

Upward Culmen ascends thro SCA occlusion cerebellar infarction

cerebellar tent hiatus Aqueduct obstrn - Hydrocephalus

Tonsillar Tonsils thro FM Medullary compression, stiff neck, skew

deviation, rapidly fatal
PICA
 Infratentorial lesions
Cause coma by affecting reticular activating
system in pons
Brainstem nuclei and tracts usually involved with
resultant focal brainstem findings
 Infratentorial causes of coma
Neoplasm
Vascular accidents
Trauma
Cerebellar hemorrhage
Demyelinating disease
Central pontine myelinolysis (rapid correction
of hyponatremia)
 Metabolic causes
Respiratory Hepatic

Hypoxia encephalopathy
Severe renal failure
Hypercarbia
Infectious
Electrolyte
Meningitis
Hypoglycemia Encephalitis
Hyponatremia
Toxins, drugs
Hypercalcemia