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ESSENTIALS OF DIAGNOSIS

  • Level of consciousness is depressed.

  • Stuporous patients respond only to repeated vigorous stimuli.

  • Comatose patients are unarousable and unresponsive.

General Considerations

The patient who is stuporous is unresponsive except when subjected to repeated vigorous stimuli, while the comatose patient is unarousable and unable to respond to external events or inner needs, although reflex movements and posturing may be present.

Coma is a major complication of serious central nervous system disorders. It can result from seizures, hypothermia, metabolic disturbances, or structural lesions causing bilateral cerebral hemispheric dysfunction or a disturbance of the brainstem reticular activating system. A mass lesion involving one cerebral hemisphere may cause coma by compression of the brainstem.

Assessment & Emergency Measures

The diagnostic workup of the comatose patient must proceed concomitantly with management. Supportive therapy for respiration or blood pressure is initiated; in hypothermia, all vital signs may be absent and all such patients should be rewarmed before the prognosis is assessed.

The patient can be positioned on one side with the neck partly extended, dentures removed, and secretions cleared by suction; if necessary, the patency of the airways is maintained with an oropharyngeal airway. Blood is drawn for serum glucose, electrolyte, and calcium levels; arterial blood gases; liver biochemical and kidney function tests; and toxicologic studies as indicated. Thiamine (100 mg), dextrose 50% (25 g), and naloxone (0.4–1.2 mg) are given intravenously without delay.

Further details are then obtained from attendants of the patient’s medical history, the circumstances surrounding the onset of coma, and the time course of subsequent events. Abrupt onset of coma suggests subarachnoid hemorrhage, brainstem stroke, or intracerebral hemorrhage, whereas a slower onset and progression occur with other structural or mass lesions. Urgent noncontrast CT scanning of the head is appropriate if it can be obtained directly from the emergency department, in order to identify intracranial hemorrhage, brain herniation, or other structural lesion that may require immediate neurosurgical intervention. A metabolic cause is likely with a preceding intoxicated state or agitated delirium. On examination, attention is paid to the behavioral response to painful stimuli, the pupils and their response to light, the response to touching the cornea with a wisp of sterile gauze, position of the eyes and their movement in response to passive movement of the head and ice-water caloric stimulation, and the respiratory pattern.

A. Response to Painful Stimuli

Purposeful limb withdrawal from painful stimuli implies that sensory pathways from and motor pathways to the stimulated limb are functionally intact. Unilateral absence of responses despite application of stimuli to both sides of the body in turn implies a corticospinal lesion; bilateral absence of responsiveness suggests brainstem involvement, bilateral pyramidal tract lesions, or psychogenic unresponsiveness. Decorticate (flexor) posturing may occur with lesions of the internal capsule and rostral cerebral peduncle and decerebrate (extensor) posturing with dysfunction ...

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