DISTURBANCES OF

CONSCIOUSNESS
 Types of disturbances of
consciousness
Reduction of the level of
consciousness
confusion (drowsiness)
stupor
coma
 Pathophysiology of coma

Demage of reticular
activating system
(brainstem)

Bilateral lesion of
cerebral cortex
Glasgow Coma Scale
I. Eyes open
spontaneously 4
To the verbal stimuli 3
To pain 2
Never 1

II. Best verbal response

Oriented and converses 5
Disoriented and converses 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1

III. Best motor response

Obeys 6
Localizes pain 5
Flexion withdrawal 4
Flexion abnormal (decorticate rigidity) 3
Exension (decerebrate rigidity) 2
No response 1
 Delirium

Illusions, hallucinations
Restlessness, hyperactivity
Suggestibility
Autonomic distorbances
Desorientation in place and/or in time
Altered mental content
 OMA
is a state of awareness of self and
surroundings
No speech, no eye opening, no motor
response
Closed eyes
No motor movements
 Types of coma

Metabolic coma (2/3) Structural lesion of

Anoxia (cardiac arest) CNS (1/3)
Overdose (barbiturates) Brain trauma
Alcoholic Stroke
Diabetes Tumor
Hepatic, renal failure Meningitis
Heat stroke
 Examination of patient with
reduction of the level of
consciousness

to assess the depth of coma

to assess respiration, cardiac function
The examination of skin
Neurological examination
The history (from whoever accompanies
the patient)
Abnormal breathing patterns

Cheyne-Stokes respiration - periodic smooth increase and decrease in

respirations from apnea to hyperpnea; occurs both in bilateral lesions
deep in the cerebral hemispheres and in metabolic coma

Central neurogenic hyperventilation metabolic acidosis (uremia,

diabetic ketoacidosis, exogenous toxins such as ethylene glycol) leads to
hyperventilation;sustained, regular,rapid, deep hyperpnea is also seen in
midbrain lesions

tactic respiration - completely irregular pattern due to a low brainstem

lesion (as with cerebellar or pontine hemorrage, medullary infarction,
trauma), but may also occur in severe meningitis
Neurological examination
Pupils (size, reaction to the light)
Eyes movements (dolls eye movement)
Symmetrical/ asymmetrical symptoms
(UMNS)
Meningeal signs
 Oculocephalic response
(dolls eye movement)

The eyes remain relatively stationary

when the head is rapidly turned to one side
Decorticate posturing Decerebrate posturing
 Treatment of comatose
patients

Assure oxygenation
Maintain the circulation by replacing blood volume looses,
maintaining cardiac rhythm
Administer IV 40-60 ml of 40% glucose and 100 mg thiamine
In narcotic coma 0,4 1,2 mg naloxone hydrochloride
treat of metabolic or respiratory alkalosis and acidosis
treat of hyperthermia
Treat infection. A patient with fever, stiff neck and coma
should have a LP immediately
osmodyaretics (mannitol)
Nootropic drugs, antixipoxants
Parenteral nutrition
 OUTCOME OF COMA

Good recovery
Neurological symptoms (hemiparesis)
Persistent vegetative state
Brain death
Death
 m-like conditions

Locked-in Apallic syndrome

syndrome

Akinetic mutism Brain death