Plum and Posner's Diagnosis and Treatment of Stupor and Coma

1. Pathophysiology of Signs and Symptoms of Coma ALTERED STATES OF CONSCIOUSNESS DEFINITIONS Consciousness Acutely Altered States of Consciousness Subacute or Chronic Alterations of Consciousness APPROACH TO THE DIAGNOSIS OF THE COMATOSE PATIENT PHYSIOLOGY AND PATHOPHYSIOLOGY OF CONSCIOUSNESS AND COMA The Ascending Arousal System Behavioral State Switching Relationship of Coma to Sleep The Cerebral Hemispheres and Conscious Behavior Structural Lesions That Cause Altered Consciousness in Humans 2. Examination of the Comatose Patient OVERVIEW HISTORY GENERAL PHYSICAL EXAMINATION LEVEL OF CONSCIOUSNESS ABC: AIRWAY, BREATHING, CIRCULATION Circulation Respiration PUPILLARY RESPONSES Examine the Pupils and Their Responses Pathophysiology of Pupillary Responses: Peripheral Anatomy of the Pupillomotor System Pharmacology of the Peripheral Pupillomotor System Localizing Value of Abnormal Pupillary Responses in Patients in Coma Metabolic and Pharmacologic Causes of Abnormal Pupillary Response OCULOMOTOR RESPONSES Functional Anatomy of the Peripheral Oculomotor System Functional Anatomy of the Central Oculomotor System The Ocular Motor Examination Interpretation of Abnormal Ocular Movements MOTOR RESPONSES Motor Tone Motor Reflexes Motor Responses FALSE LOCALIZING SIGNS IN PATIENTS WITH METABOLIC COMA Respiratory Responses Pupillary Responses Ocular Motor Responses Motor Responses MAJOR LABORATORY DIAGNOSTIC AIDS Blood and Urine Testing Computed Tomography Imaging and Angiography Magnetic Resonance Imaging and Angiography Magnetic Resonance Spectroscopy Neurosonography Lumbar Puncture Electroencephalography and Evoked Potentials 3. Structural Causes of Stupor and Coma COMPRESSIVE LESIONS AS A CAUSE OF COMA COMPRESSIVE LESIONS MAY DIRECTLY DISTORT THE AROUSAL SYSTEM Compression at Different Levels of the Central Nervous System Presents in Distinct Ways The Role of Increased Intracranial Pressure in Coma The Role of Vascular Factors and Cerebral Edema in Mass Lesions HERNIATION SYNDROMES: INTRACRANIAL SHIFTS IN THE PATHOGENESIS OF COMA Anatomy of the Intracranial Compartments Patterns of Brain Shifts That Contribute to Coma Clinical Findings in Uncal Herniation Syndrome Clinical Findings in Central Herniation Syndrome Clinical Findings in Dorsal Midbrain Syndrome Safety of Lumbar Puncture in Comatose Patients False Localizing Signs in the Diagnosis of Structural Coma DESTRUCTIVE LESIONS AS A CAUSE OF COMA DIFFUSE, BILATERAL CORTICAL DESTRUCTION DESTRUCTIVE DISEASE OF THE DIENCEPHALON DESTRUCTIVE LESIONS OF THE BRAINSTEM 4. Specific Causes of Stupor and Coma INTRODUCTION SUPRATENTORIAL COMPRESSIVE LESIONS EPIDURAL, DURAL, AND SUBDURAL MASSES Epidural Hematoma Subdural Hematoma Epidural Abscess/Empyema Dural and Subdural Tumors SUBARACHNOID LESIONS Subarachnoid Hemorrhage Subarachnoid Tumors Subarachnoid Infection INTRACEREBRAL MASSES Intracerebral Hemorrhage Intracerebral Tumors Brain Abscess and Granuloma INFRATENTORIAL COMPRESSIVE ESIONS EPIDURAL AND DURAL MASSES Epidural Hematoma Epidural Abscess Dural and Epidural Tumors SUBDURAL POSTERIOR FOSSA OMPRESSIVE LESIONS Subdural Empyema Subdural Tumors SUBARACHNOID POSTERIOR FOSSA LESIONS INTRAPARENCHYMAL POSTERIOR FOSSA MASS LESIONS Cerebellar Hemorrhage Cerebellar Infarction Cerebellar Abscess Cerebellar Tumor Pontine Hemorrhage SUPRATENTORIAL DESTRUCTIVE LESIONS CAUSING COMA VASCULAR CAUSES OF SUPRATENTORIAL DESTRUCTIVE LESIONS Carotid Ischemic Lesions Distal Basilar Occlusion Venous Sinus Thrombosis Vasculitis INFECTIONS AND INFLAMMATORY CAUSES OF SUPRATENTORIAL DESTRUCTIVE LESIONS Viral Encephalitis Acute Disseminated Encephalomyelitis CONCUSSION AND OTHER TRAUMATIC BRAIN INJURIES Mechanism of Brain Injury During Closed Head Trauma Mechanism of Loss of Consciousness in Concussion Delayed Encephalopathy After Head Injury INFRATENTORIAL DESTRUCTIVE LESIONS BRAINSTEM VASCULAR DESTRUCTIVE DISORDERS Brainstem Hemorrhage Basilar Migraine Posterior Reversible Leukoencephalopathy Syndrome INFRATENTORIAL INFLAMMATORY DISORDERS INFRATENTORIAL TUMORS CENTRAL PONTINE MYELINOLYSIS 5. Metabolic and Diffuse Encephalopathies: Disruption of the Internal Milieu DISTINGUISHING FEATURES OF METABOLIC ENCEPHALOPATHY Mental status testing, delirium, and grading level of unresponsiveness Distinguishing metabolic encephalopathy from focal causes of coma Distinguishing metabolic encephalopathy from diffuse or multifocal causes of coma Key features of the neurological exam in metabolic encephalopathy THE INTERNAL MILIEU: AN OVERVIEW OF CEREBRAL METABOLISM AND THE ENVIRONMENT NECESSARY TO MAINTAIN NORMAL NEURONAL FUNCTION Cerebral blood flow, glucose, and oxygen utilization Acid-base balance and osmolality Ionic environment in the brain and spreading depression Synaptic environment in the brain and seizures DISORDERS OF THE INTERNAL MILIEU: LACK OF SUBSTRATE Cerebral hypoxia Hypoperfusion (global ischemia, multifocal vascular compromise) Hypoglycemia Lack of metabolic cofactors (thiamine) Mitochondrial disorders DISORDERS OF THE INTERNAL MILIEU: IONIC AND OSMOTIC ENVIRONMENT Hyponatremia Hypernatremia Hypercalcemia Metabolic acidosis Hyperglycemia, hyperosmolar state Hypo-osmolar state DISORDERS OF THE INTERNAL MILIEU: HORMONAL AND TEMPERATURE Hypothyroidism Hyperthyroidism Adrenal insufficiency Hypothermia Hyperthermia DISORDERS OF THE INTERNAL MILIEU: ELECTRICAL ENVIRONMENT Seizure disorders Spreading depression DISORDERS OF THE INTERNAL MILIEU: ABNORMAL CSF PRESSURE OR CONSTITUENTS Intracranial hypertension Intracranial hypotension Subarachnoid hemorrhage Acute bacterial meningitis Chronic bacterial or fungal meningitis Viral meningitis vs. encephalitis Carcinomatous meningitis DISORDERS OF ENDOGENOUS TOXINS Hypercarbia Hepatic encephalopathy Renal failure Pancreatic encephalopathy Systemic septic encephalopathy Auto-immune disorders: specific antibodies Auto-immune disorders: acute disseminated encephalomyelitis DISORDERS OF EXOGENOUS TOXINS Sedative/hypnotic drugs and anesthetics (GABA-A receptor enhancers) Ethanol, methanol, and propylene glycol (including withdrawal) Ketamine, phencyclidine (NMDA receptor antagonists) Antidepressants Neuroleptics Opiates Aspirin and acetaminophen Overdose of unknown type 6. Psychogenic Unresponsiveness CONVERSION REACTIONS CATATONIA PSYCHOGENIC SEIZURES CEREBELLAR COGNITIVE AFFECTIVE SYNDROME ''AMYTAL INTERVIEW'' 7. Approach to Management of the Unconscious Patient A CLINICAL REGIMEN FOR DIAGNOSIS AND MANAGEMENT ALGORITHM AND PRINCIPLES OF EMERGENCY MANAGEMENT SUPPORT VITAL SIGNS: AIRWAY, BREATHING, AND CIRCULATION Ensure Oxygenation, Airway, and Ventilation Maintain the Circulation HISTORY, EXAM, AND BASIC DIAGNOSTICS Emergency Examination of the Comatose and Stuperous Patient Emergent Treatment that Should be Considered for All Patients with Stupor or Coma More Definitive Treatment of Etiologies of Stupor and Coma 8. Management of Frequently Encountered Causes of Unconsciousness MANAGEMENT OF FREQUENTLY ENCOUNTERED CAUSES OF UNCONSCIOUSNESS STRUCTURAL LESIONS: SUPRATENTORIAL OR INFRATENTORIAL COMPRESSIVE/DESTRUCTIVE ETIOLOGIES Aneurysmal Subarachnoid Hemorrhage Intracerebral Hemorrhage Traumatic Brain Injury Subdural and Epidural Hematoma Arterial Ischemic Stroke Venous Sinus Thrombosis Brain Tumor Brain Abscess NONSTRUCTURAL LESIONS: METABOLIC, DIFFUSE, OR MULTIFOCAL COMA Central nervous system infections Autoimmune causes of coma Hypoxic Brain Injury / cardiac arrest Metabolic coma GENERAL MANAGEMENT CONSIDERATIONS APPLYING TO ALL OR MOST BRAIN INJURED PATIENTS GOALS OF CARE FINAL WORD 9. Prognosis in Coma and Related Disorders of Consciousness and Mechanisms Underlying Outcomes 10. Brain Death - Joseph J. Fins DETERMINATION OF BRAIN DEATH CLINICAL SIGNS OF BRAIN DEATH Brainstem Function Confirmatory Laboratory Tests and Diagnosis Diagnosis of Brain Death in Profound Anesthesia or Coma of Undetermined Etiology Pitfalls in the Diagnosis of Brain Death Brain Death versus Prolonged Coma Management of the brain dead patient