1 / 46

Disorders of Consciousness Stephen Deputy, MD, FAAP

Disorders of Consciousness Stephen Deputy, MD, FAAP. Consciousness. Refers to the awareness of self and environment Content of Consciousness Arousal. Consciousness. Localization. Delerium.

shae
Download Presentation

Disorders of Consciousness Stephen Deputy, MD, FAAP

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Disorders of ConsciousnessStephen Deputy, MD, FAAP

  2. Consciousness • Refers to the awareness of self and environment • Content of Consciousness • Arousal

  3. Consciousness Localization

  4. 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

  5. Depressed Levels of Consciousness • Lethargy • Stupor • Sleepy Appearing • Somnolence • Obtundation • Coma

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

  7. 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

  8. 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

  9. Minimally Conscious State Severely altered consciousness but with definite behavioral evidence of awareness of self and environment

  10. 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

  11. 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

  12. 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

  13. Causes of Coma • Supratentorial Lesions (affecting Bilateral Cerebral Hemispheres/Thalamic Nuclei) • Infratentorial Lesions (Affecting the Brainstem Reticular Activating System)

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

  15. Herniation Syndromes • Subfalcine Herniation • Uncal Herniation • Central Herniation • Cerebellar Tonsillar Herniation

  16. Regions of Brain Herniation

  17. Sub-Falcine Herniation

  18. Notching of the UncusDue to Transtentorial (Uncal) Herniation

  19. Downward Cerebellar Tonsillar Herniation through the Foamen Magnum

  20. Duret Hemorrhages of the PonsFrom Brainstem Herniation

  21. CT BrainSubdural Hematoma Subfalcine and Transtentorial Herniation

  22. CT Brain Intraventricular Hemorrhage,Hydrocephalus, and Central Herniation

  23. 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)

  24. 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

  25. Evaluation of Coma Neurological Examination • Mental Status • Cranial Nerves • Motor Examination • Sensory Examination

  26. Evaluation of Coma Mental Status • Describe what you see • Best Eye Opening, Vocalization, and Motor Response to various Forms of Stimuli • Glasgow Coma Score

  27. Eye Opening Glasgow Coma Scale Motor Response Verbal Response

  28. Glasgow Coma Scale(For Infants) Eye Opening Motor Response Verbal Response

  29. Cranial Nerves II (optic Nerve) • Fundoscopic Exam • Pupillary Light Reflex

  30. Pupils Size Based on Localization

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

  32. Oculocephalic Reflex(Doll’s Eyes and Cold Calorics)

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

  34. Cranial Nerves IX and X The Gag Reflex • IX is Afferent • X is Efferent

  35. Cranial Nerves Respiration • Respiratory Patterns Based on Localization • The Apnea Test

  36. Breathing Patterns Based on Level of Brainstem Dysfunction

  37. 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

  38. Motor Examination Spontaneous Movement Response to Noxious Painful Stimuli • Localizes Pain • Withdraws from Pain • Decorticate Posture • Decerebrate Posture • No Movement

  39. Decorticate Posturing

  40. Decerebrate Posturing

  41. 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

  42. 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

  43. 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”

  44. 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)

  45. 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)

  46. That’s All Folks

More Related