1. Disorders of Consciousness Stephen Deputy, MD, FAAP

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

3. Consciousness 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 Uncus Due to Transtentorial (Uncal) Herniation

19. Downward Cerebellar Tonsillar Herniation through the Foamen Magnum

20. Duret Hemorrhages of the Pons From Brainstem Herniation

21. CT Brain Subdural 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. 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

28. 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

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