Coma and Brain Death

A. See also

B. Levels of decreased consciousness

1. Confusion: Decreased attention but relatively normal alertness.
2. Drowsiness: (∼lethargy, somnolence). Arouses to voice and can respond verbally.
3. Stupor: (∼obtundation). No response to voice, no spontaneous speech. Incomplete but purposeful response to pain.
4. Coma: Nonpurposeful or no response to pain (“unarousable unresponsiveness”).

C. Other alterations in consciousness

D. Initial coma evaluation

CPR if needed → IV access → draw labs (include tox screen, ?carbon monoxide level) → give dextrose, thiamine, naloxone → do coma exam (see below) → treat suspected high ICP, meningitis, or seizures → get head CT → treat metabolic problems.

E. Coma exam

VS (and note pattern of breathing), cardiac rhythm, response to voice, lids (spontaneously closed?), pupils, eye movements (spontaneous, doll’s, calorics), corneals, grimace to nasal tickle, gag, cough, motor response to pain, tone (lift and drop arm), reflexes.

1. Decorticate posturing (lesion is above midbrain):
- a. Arm: Flexed elbow, wrist, fingers.
- b. Leg: Extended and internally rotated leg, with plantar flexion.
2. Decerebrate posturing (lesion is above medulla):
- a. Head: Clenched jaw, extended neck.
- b. Arm: Adducted and internally rotated shoulder, extended elbow, pronated wrist, flexed fingers.
- c. Leg: Extended and internally rotated leg, plantar flexion.