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A Practical Approach to Coma Diagnosis in the Unresponsive Patient

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A Practical Approach to Coma Diagnosis in the Unresponsive Patient A practical approach to coma diagnosis in the unresponsive patient MARTIN A. SAMUELS, MD • Diagnosis of coma in the unresponsive patient can be done in a relatively short time by making key observations that will confirm disease of either the brain stem or the hemispheres, the two locations in which coma originates. Determining the location of the lesion is the primary goal in early assessment of the unresponsive patient. Examination of the patient's eyes is the single most important step in understanding coma. • INDEX TERMS: UNCONSCIOUSNESS; BRAIN STEM; EYE MANIFESTATIONS; 0 CLEVE CLIN J MED 1992; 59:257-261 IAGNOSIS OF THE unresponsive patient coma, the deepest level of unconsciousness. The varia- is a major issue in the practice of neurologi- tions in a patient's mental status along the spectrum cal medicine, internal medicine, and emer- are somewhat analogous to the conditions produced by gency medicine. If the patient is in a coma, anesthesia. The first signpost is confusion or inatten- Dthe disease is either in the ascending reticular activat- tion, the inability to maintain a coherent stream of ing system (a diffuse array of nuclei and tracts extend- thought or action. The ability to count backwards by ing from the brain stem to the thalamus), or the disease sevens from 100 (the "serial sevens" test) is a classic is bilateral and diffuse in the hemispheres. In assessing test of attention. Drugs, toxins, and metabolic en- an unconscious person, the primary goal is to deter- cephalopathy can cause inattention or confusion, mine the location of the lesion. Certain simple obser- which is the most common abnormality in mental vations made in an orderly fashion will provide the status seen in a general hospital setting. Generally, the information necessary for a diagnosis in an hour's time. cause can be attributed to drugs. The next step toward coma is drowsiness, the state DEGREES OF UNCONSCIOUSNESS of apparent sleep that is overcome with a verbal com- mand. A still greater degree of unconsciousness is The unresponsive patient may be at any depth of stupor, in which the patient looks asleep, cannot be unconsciousness along a spectrum from nearly alert to aroused by a verbal command, but responds to a painful or noxious stimulus. Placing a small piece of cotton inside the patient's nostril will produce the necessary From the Department of Neurology, Harvard Medical School, stimulus, as well as provide a means for assessing the Boston. motor system of the comatose person. Address reprint requests to M.S., Division of Neurology, Brigham The greatest degree of unconsciousness is coma, in and Women's Hospital, 75 Francis Street, Boston, MA 02115. *This article was adapted from a talk given at The Cleveland which a stimulus produces either a reflex response or Clinic Foundation's "Intensive Review of Internal Medicine" no response at all. When a stimulus elicits antigravity MAY • JUNE 1992 CLEVELAND CLINIC JOURNAL OF MEDICINE 2 31 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. Coma • SAMI KI.S posturing from the comatose person, the response tal meningioma, metastatic or primary tumors, hemor- could indicate either decerebration or decortication, or rhages in the brain, and contusions. Prefrontal lobe both. In humans, the location of lesions in decerebra- disease, usually bilateral, tends to produce abulia. An tion or decortication is not well defined, but both are unusual and unexplained characteristic of abulic common in coma caused by brain stem pathology. patients is their ability to carry on a telephone conver- Finally, pseudocoma, or hysterical coma, is a condi- sation, even though they are unable to talk face-to- tion in which the patient is in a deep trance and face. This phenomenon is called the "telephone sign" cannot be aroused by painful stimuli. A coma for which and is almost pathognomonic of frontal lobe trouble. there is no physiological cause, pseudocoma is diag- In this situation, the clinician can resort to taking a nosed by excluding all known causes of coma. history via telephone. Among psychiatric conditions, only catatonia and CHARACTERISTICS OF COMA the dissociative state can produce akinetic mutism. Catatonic schizophrenia, once a common disease and Consciousness is characterized by two qualities: (1) still prevalent in developing countries, is now very rare wakefulness, which is regulated by nuclei in the core of in industrialized societies. A century ago, catatonic the brain stem, and (2) awareness, which is controlled schizophrenics existing in states of waxy rigidity as in the cortex, bilaterally and diffusely. Conversely, un- immobilized akinetic mutes were a common sight in consciousness has two qualities: (1) permanent un- mental hospitals. Today, however, catatonia is general- wakefiilness and/or (2) lack of awareness. Accordingly, ly produced by severe depression. there are only two causes of unconsciousness: (1) brain The dissociative state, in which part of the per- stem coma, which looks like sleep and renders a sonality is split off from the rest, can produce hysterical patient incapable of arousal, and (2) bilateral hemi- mutism. Such patients may believe that a weakness of sphere disease, in which the patient looks awake but is their nervous system renders them incapable of speak- neither aware nor able to respond in any way to any ing above a whisper. Speech therapy over a period of stimulus. The latter, which may be termed "hemi- several weeks may "give the patient a way out" and sphere coma," is often regarded as a "vegetative state." restore the ability to speak. From a practical perspective, determining whether The "locked-in" syndromes refer to patients who are the patient looks awake or asleep is the first observa- paralyzed and are, in fact, awake. The classic condition tion to be made, for it reveals something about the is the pontine infarct, but high cervical spinal cord underlying pathogenesis of unresponsiveness. In assess- injuries and severe dystonias from drugs like prochlor- ing unresponsive patients, two important points should perazine can also cause paralysis and acute loss of func- be stressed. First, assume that the unresponsive patient tion. can hear every word that you speak. Second, never move the head or neck of an unresponsive patient, DIAGNOSIS OF THE COMATOSE PATIENT awake or asleep, until the possibility of a neck injury has been ruled out. The history In dealing with a comatose patient, who is incapable Unresponsive, with open eyes of providing a history, it is important to find family, Although the unresponsive patient who appears to police, ambulance personnel, or anyone who can pro- be asleep is the type of patient commonly seen, it is vide the answers to key questions in the history. How appropriate to discuss the unresponsive patient whose rapid was the onset? Are there possible drugs or toxins? eyes are open and who appears to be awake. The un- Has this happened before? responsive patient who appears to be awake is actually Studies have shown that drugs and toxins are the in a state of akinetic mutism, which may be attributed most common causes of coma in emergency depart- to one of three syndromes—abulia, psychiatric dis- ments, regardless of socioeconomic status. All drugs— eases, and locked-in syndromes. over-the-counter, prescription, and illegal, including Abulia is the absence of effervescence and spon- alcohol—taken singly or in combination, are suspect. taneity. The abulic patient will respond in a slow, vis- Trauma, fever, and headaches are all obvious clues cous manner, with long delays between the question in the diagnosis of coma. The trauma that occurred in and answer. Abulia of varying degrees can be caused by the recent past, however, is an important part of the a number of conditions, including hydrocephalus, fron- history that must be provided by family or friends. The i 10 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 59 NUMBER 3 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. l'OMX • S\Ml H - simple question "Any theories?" can often elicit vital Testing for eye movements information from family members. The eye movements come from the brain stem. It follows, therefore, that if the eyes are moving, the Examination of the patient brain stem is intact. However, if the eyes are roving, If the history has failed to differentiate between with rapid and smooth motion, a loss of inhibition hemisphere disease and brain stem disease, an evalua- resulting from bihemisphere coma is indicated. On the tion of brain stem functions is the appropriate next other hand, if the eyes aren't moving, it will be neces- step in the examination of the comatose patient. sary to make them move. Since one must never turn The brain stem sets posture. If, therefore, the the head of a comatose patient, it is impossible to use patient looks comfortable, the brain stem is not in- the doll's head maneuver to test the vestibular ocular volved. On the other hand, a patient who looks un- reflex, which tends to turn the eyes in the direction comfortable is likely to have a brain stem problem. opposite that in which the head is turned. The alterna- This is an important triage point and one that can be tive practice of putting ice water in one ear inactivates made by radio communication with an emergency the vestibular system on that side for about 30 to 40 medical technician in the field. seconds, thus achieving the same effect as that of turn- Respiratory patterns are useful in the diagnosis of ing the head. the source of the coma. Cheyne-Stokes breathing is a The diagnosis of the comatose patient with no eye complicated respiratory pattern that is not seen in the movement can be accomplished by putting 50 mL of ice critically ill patient with brain stem disease.
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