PHYSICAL 57 Definition SUZIE C. TINDALL ‘The normal sate of consciousness comprises either the state of wakefulness, awareness, or alertness in which most hu- man beings function while not asleep or one of the recog- nized stages of normal sleep from which the person can be readily awakened, The abnormal state of consciousness is more difficult to define and characterize, a8 evidenced by the many terms applied to altered states of consciousness by various ob- servers. Among such terms are: clouding of consciousness, confusional state, delirium, lethargy, obtundation, stupor, dementia, hypersomnia, vegetative state, akinetic mutism, locked-in syndrome, coma, and brain death, Many of these terms mean different things to different people, and may prove inaccurate when transmitting and recording infor- Imation regarding the state of consciousness of a. patient, Nevertheles, itis appropriate to define several ofthe terms as closely as possible Clouding of consciousness sa very mild form of akered mental status in which the patient has inattention and reduced, wakefulness Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following. commands. Lethergy consists of severe drowsiness in which the patient ‘an be aroused by moderate stimuli and then drift back to sleep. ‘Obtundation isa state similar to lethargy in which the patiene hhas a lessened interest in the environment, slowed re- sponses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states. Table 57.1 Grady Goma Scale Level of Consciousness ‘Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back wo the unresponsive Coma is a state of unarousable unresponsiveness, Its helpful to have a standard scale by which one can measure levels of consciousness. This proves advantageous for several reasons: Communication among health care personnel about the neurologic condition of a patient is Improved: guidelines for diagnostic and therapeutic inter- vertion in certain situations can be linked to the level of ‘consciousness; and in some situations a rough estimate of prognosis can he made based partly on the scale score. In order for such a scale to be useful it must be simple to learn, ‘understand, and implement. Scoring must be reproducible ‘among observers. The Grady Goma Scale (Table 97.1) has [proved functional in chis regard. It has been used for more than 10 yearsat Grady Memorial Hospital in Addanta, Geor- aia, to gauge the level of consciousness of patients in the ‘neurosurgical intensive care unit and elsewhere. The grade patient is only slightly confused. ‘The grade I patient requires a light pain stimulus (such as a sharp pin ped lightly over the chest wall) for appropriate arousal, or may be combative or belligerent, The grade ILI patient is com- atoxe but wll ward off deeply painful stimuli such as ternal pressure or nipple twist with an appropriate response. The grade IV patient reacts inappropriately with either dec ticate or decerebrate posturing to such deeply painful stim- uli, and the grade V patient remains flaccid when similarly stimulated, Many other coma scales have been developed. Most are tailored to specific subsets of patients and are designed not only to reilect level of consciousness but also to include additional data so that more reliable comparisons can be Responds appropriately to: Calling Light Deep Grade State of awareness ‘name pin pain 1 Gonfased, drowsy, lethargic, indifferent ander uncooperative: doesnot lapse into sleep when lett Yes Yes. Yes tindisturbed 11 Stuporous; may be disoriented to time, place, and persons wil Inpse into sleep when not disturbed; NoYes Yes for belgerent and uncooperative IL Deep stupor: requires strong pain to evoke movement No ver IV Exhibits decorcate or decerebrate posturing 10a deep pain stimulus No No Does not respond to any stimuli Macc No No No 296,57. LEVEL OF CONSCIOUSNESS 297 made for research purposes or more reliable prognostic determinations can be made. An example of such a scale is, the Glasgow Coma Scale (Table 57.2). In this scale the nor: mal state merits a score of 19, and as level of consciousness deteriorates, the score becomes less Technique “The technique of evaluation of the patient with an altered level of consciousness can be divided into three phases. The first is to determine the level of consciousness itself. Second is evaluation of the patient, searching carefully for hints as to the eause of the confusion or coma Third is the presence fo absence of focality of the disorder, both in terms of the level of dysfunction within the rostrocaudal neuraxis and specific involvement of cortical or brainstem structures. After the physician makes sure that no immediate life. threatening emergency such as airway obstruction or shock is present, the examination begins with observation of the patient, What isthe pesition of the patient? Does the patient 1ave one or more extremities positioned in an unusual man- ner, which might suggest paralysis or spasticity? Are the ‘eyes opened or closed? Does the person acknowledge your presence, or is he or she oblivious to it? If the patient is alert, acknowledges the presence of the examiner, seems ‘well oriented to time and place and not confused on general questioning, then the level of consciousness would be eo sidered normal. Thus one cin have a normal level of co sciousness yet be of subnormal intellectual capability, have 2 focal neurologic deficit such asan aphasia or hemiparesis, fr exhibit abnormal thought content such asa schizophrenic patient might. As the patient’ name is called in a normal wne of voice or if, during an attempt ata simple conversation, itis noted that the person is confused, drowsy, or indifferent, an ab- normal level of consciousness exists. Individuals who re- spond with recognition when their name is called and do not lapse into sleep when left undisturbed, can be said 10 be in a grade I coma. Ifthe alteration in level of conscious. ness is more severe, so that the person lapses into sleep when not disturbed and is arousable only when a pin is tapped gently over the chest wall, the grade of coma is I. Table 572 Glasgow Coma Seale pares 3 Opens eyes t voice ees Sires ere Le Ee ne : ‘Abnormal exensor sponse No movement, ™ ‘Bost verbal respnse(V) 5. Appropriate and oriented 3: Inappropriate word 2. Incomprebersble sounds 1. Nowunds “This category also includes the patient who is onganically dlsoriemel, belligerent, and uncooperative (as can be se in various sates invocation), nthe young adult with tmodcrately severe head injury. ‘such efforts as calling the patient's name in a normal tone of voice or pricking the skin over the chest wall lightly tru «pin result in no response the examiner mut choose 1eeper pun stimulus By preference isa pinch or sight twist ofthe nipple. Other options include sternal pressure, which may beapplied with te fisted knuckle, or queeding the mabe. he slight periateoar bruising from repetitive nipple twating is much lee problematic tothe eventually feeovered pant than the chtonialy painful subperiosteal tr subungoal hemnorthage from the ter options. Under no circumstances should one appy such a painful simul as ivigation of the ears wih ic water un the stats of the inuactaial pressure is Known. The patients reponse t the deep pain stimulus is then noted A patient wh winces fndlor steps to ward of the deep pai simulisappro- priate can be sud tobe in grade Ul coma, “The deep pain stimulus may, however, ceuk in abnor- imal postural rellexes, ether undateralor bateral. The two mod! common are decorate and decerebrate posturing. In be tacen the kower extremity exhibits extension 3 the knee and internal rotation and planar flexion at the ankle In decortente pouring, the upper exremiy held ad Ahcted atthe shoulder an flexed at the elbow, wrt, and imctacarpalphalangeal int Inthe decerebrate ate, he upper curemity B adduced atthe shoukler and rigidly txtended and internally rotated a the elbow I ether ese, the patenteshibing ach posturing woa deep pan sta, israedsa grade IV coma. Pie patio who matoain a sate Gf Maced unresponsiveness despite deep pain simulation inaigrade V coma ‘Goce the ler! of consclousness a determined, carefol clech for hints a othe cause ofthe aeration i eve of consciousness shoul be undertaken, tn most instances the Iatory (which can be obtained from the patient or those tthe accompany bin, or from avaiable medial records) Is tore valuable than the exaration, Histor snot aly dralable, however, and in all ingances a carefel examiner thon it merited. Vil sgns may obviously suggest infection, hypercension, shock, or increased itacrania presare with bradycardia is there evidence of trauma tothe bead cleewhere? Inspect the valp thoroughly for abrasions Contusons, and if blood is seen, explain i even if t means shaving par of the salp to do sos there periorbital or Fetroaureulareachymost ors thre bod behind the panic membrane w suggest bar skull ature? Is there Papilledema or inraoclar hemorrhage? Isthe conjunc Iter the ver enlarged, or doc the patent have ters? [Ave the ipso haibeds discolored of peso wr suggest anemia of pulmonary dstuncion? fo the neck sthte warning of mening or subarachnoid hemorshage ts there Srything to soqges inicaton wah drugs or poor, such as In unusual dor tothe breath or body or pinpoint pups? “The next sep & to try to localize the proslem that is resuking in akeration of conscousness, fist by ying to ioalire the dysfunction toa level wah the ronrocadal eras and second by searching for focal cues such a8 ‘pectic cranial nerve fics, abnormal elev, or mOIoT Fancy "The level of conaciousnes determines toa certain exent the level of fetional disturbance within the neuron, A Patent who qualifies asa grade tor Il has coral or di298 WV. ‘THE NFUROLOGIC sysTEM cephalic dysfunction, ‘The grade 1 patient has physiologic Syafanction above the midbrain. Case 1V conta indicates Syafunction above the levels of the cercbral peduncles poms, and with grade V coma the medulla may be al that EB working, Observation ofthe pattern of respiration may further support the examiner's impression of dysfunctional level (Table 57.3). Cheyne-Siokes respiration means rouble aot above the diencephalon; central neurogenic hyper. ‘entiation (which i rare) points to dificult atthe upper Iidbrain;apnenstic respiration suggests functional pontine deci; and an ataxic breathing pattern suggests, dorso- ‘edi medullary dysfunction. Observation ofthe rate, pat tern, and depth of respiration over at leat several mites is necessary to document such alterations. Like respiratory patterns, the size and reactivity ofthe pupils can be used to substantiate further the level of dysfunction within the neuraxis (Table $7.4). Small reactive pupil sugges din: Cephalic loalietion,frequendy on a metabolic basis Large Pupils that dist and contrac automatically (kippus) bat Afonot react to direct ight stubs sugges tec lesion Midpostion fixed pup localize to te tidbain, Biter none pup are indicative of pontine trouble. Beamon ofthe vealed tenner reese of roa importance in evaluation of the patient in grade II, IV? or Vcoma (Table 57.5). Allyely om inteuity of centers within the pon or dorsal midbrain, As emphanved ear, the cold-water caloni tes should pore dane unl the satis ofthe patents intracranial presure is kaown.Irgation of the eardrum with fe water catses such pain thatthe pa tent’ Valea response may be enough to inate hernia tion in the aeady tenuous station of markedly increased intracranial presure: Siygested methods for testing these feflexes are outlined in Table 37.5. Further examination may be productive in revealing findings such asa unilateral dilted pupil,» focal cranial nerve deft an asymmetry of movement siggesing ahem iparesis abnormal movement suggesting sere act, a fellex asymmety, ora foal sensory abnormality that wil telp further localize the area of trouble within the central ftervous system. The specific techniques for such exami talon ae covered caewhere Table 573 Some Abnormal Respiratory Patterns Found in Comatose Patients Patern Deseipion Cheyne-SiokesPevidic breathing in which ass of hyperpes hemiopheres: Eicnnewibafecs he dientptnion phases sera every 3010 Tetcconds Cental Deep, rap respraons ata Miabrain; scuogenic cov mrcinn — Gencephalon Typerttaion Apneustic A prolonged inspiratory Pontine Secamp''s prokanged gasp tegmentam asic Random sequences of Medill shallow and deep respi ‘without pattern Table 57.4 Possible Pupillary Patterns in Comatose Patients Pattern Sie of dysfunction Sell, eaetive Diencephalon Large “Bxed” with hippos Mibrain tectum Muposition, “fixed” Midbrain Pons Suggests transtentoral ibeniation Basic Science The exact neuronal connections that modulate alertness, wakefulness, and normal sleep and drowsiness are not well, defined. A distinet group of neurons, the reticular forn tion, is located in the periventricular areas of the midbrain, pons, and medulla, In addition to modulating various in- terconnecting pathways within the brainstem, this group of neurons relates to the levels of alertness and wakefulness Tis postulated that a diffuse group of neuronal connections emanates from this reticular formation, projecting up the ‘midbrain into the thalamic structures and then on 10 the cortex, This system is referred (o a the ascending reticular activating system (ARAS). The ARAS receives input from all sensory systems, and efferent connections are extensive, It is thought that this system is responsible for modulating alertness and sleep. As such, any interruption ofthis system could result in alteration in the level of consciousness (or inn abnormalities in the sleep cycle) The mechanisms producing dysfunction of the ARAS are varied and strongly dependent on the etiology of the illness. In some instances, there may be more than one factor contributing to deterioration in the level of con- sciousness. For instance, metabolic and toxic diseases gen- ‘Table 57.5 Brainstem Reflexes elles Technique ‘Localization Pupillary light Shine light on pupil and Midbrain and action ‘observe constricion pontine : aie pacer, erat espe lightly stroke cornea. ‘inh cotton sp ‘observe for blink Hold is open sith one Pons—vesibular hhand wee turing head side to side wih the ether hard observe rotation of tyes side to side Oculovestbular; With head at $0 Pons-—vestibular wok seter degtecs rite ‘alories external auditory ‘nal and tympanic ‘membrane slowly with upto [20 mice trite; observe for Conugate rotation of the eyes toward the Side irigated