Disorders of Consciousness Stephen Deputy, MD, FAAP

Consciousness Consciousness Refers to the awareness of self and environment Content of Consciousness Arousal

Consciousness Consciousness Localization

Delerium 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 Consciousness Lethargy Stupor Sleepy Appearing Somnolence Obtundation Coma

COMA Unarousable Unresponsiveness Consciousness: None Eyes: Do not open to any stimulus Vocalization: None Motor: No purposeful movements

COMA 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 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 State Severely altered consciousness but with definite behavioral evidence of awareness of self and environment

Minimally 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 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 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 Coma Supratentorial Lesions (affecting Bilateral Cerebral Hemispheres/Thalamic Nuclei) Infratentorial Lesions (Affecting the Brainstem Reticular Activating System)

Causes of Coma Toxic/Metabolic Disorders Infectious/Post-Infectious Trauma Seizure/Post-Ictal State Neoplastic/Paraneoplastic Structural Vascular

Herniation Syndromes Subfalcine Herniation Uncal Herniation Central Herniation Cerebellar Tonsillar Herniation

Regions of Brain Herniation

Sub-Falcine Herniation

Notching of the Uncus Due to Transtentorial (Uncal) Herniation

Downward Cerebellar Tonsillar Herniation through the Foamen Magnum

Duret Hemorrhages of the Pons From Brainstem Herniation

CT Brain Subdural Hematoma Subfalcine and Transtentorial Herniation

CT Brain Intraventricular Hemorrhage, Hydrocephalus, and Central Herniation

Evaluation 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 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 Coma Neurological Examination Mental Status Cranial Nerves Motor Examination Sensory Examination

Evaluation 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 Scale Eye Opening Spontaneous4 To Verbal Command 3 To Pain2 None1 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 Scale (For Infants) Spontaneous4 To Speech3 To Pain2 None1 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 Nerves II (optic Nerve) Fundoscopic Exam Pupillary Light Reflex

Pupils Size Based on Localization

Cranial Nerves III, IV, VI (EOM’s) Doll’s Eyes Maneuver Cold Calorics

Oculocephalic Reflex (Doll’s Eyes and Cold Calorics)

Cranial Nerves V and VII (Trigeminal and Facial Nerve) Corneal Blink Reflex V-1 Afferent VII Efferent

Cranial Nerves IX and X The Gag Reflex IX is Afferent X is Efferent

Cranial Nerves Respiration Respiratory Patterns Based on Localization The Apnea Test

Breathing Patterns Based on Level of Brainstem Dysfunction

Cranial 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 Examination Spontaneous Movement Response to Noxious Painful Stimuli Localizes Pain Withdraws from Pain Decorticate Posture Decerebrate Posture No Movement

Decorticate Posturing

Decerebrate Posturing

Motor 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 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 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 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 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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