Stupor and coma

Question 1

Definitions of arousal 1

Answer 1

• Consciousness: state of full awareness of self and one’s relationship to environment
• Delirium: disturbance of consciousness with reduced ability to focus, sustain, or shift attention (develops over short period of time and leaves relatively quickly)
• Obtunded: mild to moderate reduction in alertness, accompanied by a lesser interest in environment. Slow physiologic responses to stimulation (even more unresponsive than delirium)

Question 2

Definitions of arousal 2

Answer 2

• Stupor: deep sleep or unresponsiveness, but can be aroused w/ vigorous and continuous stimulation
• Coma: state of unresponsiveness in which eyes are closed and cannot be aroused from vigorous stimuli
• Minimally conscious state: severely impaired consciousness in which minimal but definite evidence of behavior or environmental awareness is demonstrated (typically transition from conscious -> unconscious)
• Vegetative state: crude cycling of arousal states heralded by appearance of “eyes-open” periods in an unresponsive patient (no interaction w/ outside world)
• Persistent vegetative state: vegetative state for 30 days

Question 3

Pathophysiology of consciousness

Answer 3

• Bithalamic tracts, bihemispheric tracts, and the reticular activating system (RAS) are all responsible for maintaining consciousness
• These pathways can be damaged (either structurally or non-structurally) to reduce consciousness
• Structural damage: tumors, stroke, hemorrhage, abscesses, ect
• Non-structura: infections, drugs, metabolic disorders, ect

Question 4

Approach to the comatose pt

Answer 4

• Level of consciousness
• Pattern of breathing
• Size and reactivity of pupils
• Eye movements and oculovestibular responses
• Skeletal motor responses

Question 5

General examination of comatose pt

Answer 5

• Examine the room (ventilator, sedative, ect)
• Physical: signs of trauma, check skin, resistance of neck to flexion
• Coma exam: Determine intensity of stimulation (voice, shaking, pain) required to get a response and the quality of the response

Question 6

Decorticate vs decerebrate

Answer 6

• Decorticate: flexor posturing of upper extremities and extension of lower extremities (can be unilateral)
• In upper midbrain and higher (above red nucleus)
• Decerebrate: extensor posturing of both upper and lower extremities (can be unilateral)
• Progression of lesion to red nucleus (and below)