Transcript Decorticate Posturing

Disorders of Consciousness
Stephen Deputy, MD, FAAP
Consciousness
• Refers to the awareness of self and
environment
• Content of Consciousness
• Arousal
Consciousness
Localization
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
Depressed Levels of Consciousness
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Lethargy
Stupor
Sleepy Appearing
Somnolence
Obtundation
Coma
COMA
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Unarousable Unresponsiveness
Consciousness: None
Eyes: Do not open to any stimulus
Vocalization: None
Motor: No purposeful movements
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
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
Minimally Conscious State
Severely altered consciousness but with
definite behavioral evidence of awareness
of self and environment
Minimally Conscious State
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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
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
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
Causes of Coma
• Supratentorial Lesions (affecting Bilateral
Cerebral Hemispheres/Thalamic Nuclei)
• Infratentorial Lesions (Affecting the
Brainstem Reticular Activating System)
Causes of Coma
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Toxic/Metabolic Disorders
Infectious/Post-Infectious
Trauma
Seizure/Post-Ictal State
Neoplastic/Paraneoplastic
Structural
Vascular
Herniation Syndromes
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Subfalcine Herniation
Uncal Herniation
Central Herniation
Cerebellar Tonsillar Herniation
Regions of Brain Herniation
Sub-Falcine Herniation
Notching of the Uncus
Due to Transtentorial (Uncal) Herniation
Downward Cerebellar Tonsillar Herniation
through the Foamen Magnum
Duret Hemorrhages of the Pons
From Brainstem Herniation
CT Brain
Subdural Hematoma
Subfalcine and Transtentorial Herniation
CT Brain
Intraventricular Hemorrhage,
Hydrocephalus, and Central Herniation
Evaluation of Coma
Patient Stabilization (ABCD’s)
History
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Duration and Onset of Coma
Trauma
Past Medical History
Medications (Perscribed, OTC, Illicit, Accessable)
Family History (Others affected)
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
Evaluation of Coma
Neurological Examination
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Mental Status
Cranial Nerves
Motor Examination
Sensory Examination
Evaluation of Coma
Mental Status
• Describe what you see
• Best Eye Opening, Vocalization, and
Motor Response to various Forms of
Stimuli
• Glasgow Coma Score
Glasgow Coma Scale
Eye Opening
Spontaneous
4
To Verbal Command
3
To Pain
2
Localizes Pain
None
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Withdraws to Pain
Verbal Response
Oriented and Converses
5
Confused Conversation
4
Inappropriate Words
3
Incomprehensible Sounds 2
None
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Motor Response
Obeys Commands
Decorticate Postures
Decrebrate Postures
None
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Glasgow Coma Scale
Eye Opening
Spontaneous
(For Infants)
Motor Response
4
To Speech
3
Normal Spontaneous
Movements
To Pain
2
Withdraws to Touch
None
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Withdraws to Pain
Verbal Response
Abnormal Flexion
Coos Babbles
Irritable
Cries to Pain
Moans to Pain
None
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Abnormal Extension
None
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Cranial Nerves
II (optic Nerve)
• Fundoscopic Exam
• Pupillary Light Reflex
Pupils Size Based on Localization
Cranial Nerves
III, IV, VI (EOM’s)
• Doll’s Eyes Maneuver
• Cold Calorics
Oculocephalic Reflex
(Doll’s Eyes and Cold Calorics)
Cranial Nerves
V and VII
(Trigeminal and Facial Nerve)
Corneal Blink Reflex
• V-1 Afferent
• VII Efferent
Cranial Nerves
IX and X
The Gag Reflex
• IX is Afferent
• X is Efferent
Cranial Nerves
Respiration
• Respiratory Patterns Based on Localization
• The Apnea Test
Breathing Patterns Based on Level of
Brainstem Dysfunction
Cranial Nerves
The Apnea Test
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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
Motor Examination
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Spontaneous Movement
Response to Noxious Painful Stimuli
Localizes Pain
Withdraws from Pain
Decorticate Posture
Decerebrate Posture
No Movement
Decorticate Posturing
Decerebrate Posturing
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
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
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”
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)
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)
That’s All Folks