brain, spinal cord, and nerve disorders
Stupor and Coma
Diagnosis of Stupor and Coma
A doctor's evaluation Neurologic examination Laboratory and imaging tests Doctors can tell that consciousness is impaired based on observation and examination. Doctors try to identify the parts of the brain that are impaired and the cause of impairment because treatment differs and because impairment may progress, leading to coma and brain death. Stupor is diagnosed when vigorous, repeated attempts arouse the person only briefly. Coma is diagnosed when the person cannot be aroused at all and the eyes remain closed. People who become stuporous or comatose must be taken to the hospital immediately because either state may be caused by a life-threatening disorder. Health care practitioners try to identify the cause and provide emergency medical care at the same time. For example, a quick test is done to estimate the blood sugar level. Then if people have a low blood sugar level (which can quickly and permanently damage the brain), it can be treated immediately. A stuporous or comatose person cannot communicate. So the doctor usually checks whether the person is wearing a medical alert identification bracelet or necklace, which may suggest the cause. The doctor may check the person's wallet, purse, or pockets for medical identification (such as a hospital identification card) or drugs, which may also help identify the cause. Thus, a person with a disorder that increases the risk of stupor or coma (such as diabetes or a seizure disorder) should carry or wear some form of medical identification. The doctor asks any witnesses of the change in consciousness about the circumstances in which it occurred and any other symptoms the person had. For example, if the person's limbs jerked repeatedly when consciousness was affected, the cause may have been a seizure. The doctor also talks to family members and friends, who should honestly provide emergency medical personnel or the doctor with any relevant information about the person, which includes the following: Whether the person uses drugs (prescription and recreational), alcohol, or other toxic substances and which ones are used Whether the person was injured before the change in consciousness When and how the problem began Whether the person has or has had any infections, other disorders (such as diabetes, high blood pressure, a seizure, or a thyroid, kidney, or liver disorder), or other symptoms (such as headaches or vomiting) When the person last seemed normal Whether the person had eaten any unusual foods or been traveling Whether they have any hunches about what might be the cause (for example, if the person was recently depressed or talked about suicide) This information can help doctors identify possible causes and helps them assess how likely the person is to recover. Many such causes would not be identified, even with extensive diagnostic testing, if this information was unavailable. For example, if people have eaten unusual foods, the cause may be a toxin (such as those in poison mushrooms). If people have traveled recently, the cause may be an infection that is common in the area they visited. If empty pill containers or drug paraphernalia were found nearby, the cause may be a drug overdose. If a drug or toxic substance was ingested, family members or friends should give a sample of that substance or its container to the doctor. Information from friends and family members is often more helpful in determining the cause of coma than diagnostic tests. Information from the family and friends is usually valuable and is more likely to lead to the correct diagnosis than examination or testing. For example, no test can rule out all possible drug overdoses. Body temperature is checked. An abnormally high temperature may indicate infection, heatstroke, or an overdose of a drug that stimulates the body (such ascocaineor anamphetamine). An abnormally low temperature may indicate prolonged exposure to cold, an underactive thyroid gland, alcohol intoxication, a sedative overdose or, in older people, infection. Doctors examine the head, face, and skin for clues to the cause, such as the following: Black eyes, cuts, bruises, or leakage of cerebrospinal fluid (the fluid that surrounds the brain) from the nose or ears suggests a head injury. Needle marks suggest an overdose of a drug, such as heroin. Fever with a rash often suggests an infection, such as sepsis (a serious bodywide response to a bloodstream infection) or a brain infection. Certain odors on the breath suggest Diabetic Ketoacidosis or consumption of a poison or large amounts of alcohol. If people have bitten their tongue, seizures may be the cause. A thorough Neurologic Examination is done. This examination helps doctors determine How severely consciousness is impaired Whether the brain stem is functioning normally What part of the brain is damaged What the cause may be If people are unconscious, doctors try to rouse them first by speaking to them, then by touching their limbs, chest, or back. If these measure do not work, doctors use stimuli that cause discomfort or pain, such as pressure on a nail bed or a pinch. If people open their eyes or grimace when a painful stimulus is applied or if they purposefully withdraw from it, consciousness is not severely impaired. If people can make sounds, the cerebral hemispheres are functioning to some degree. If the eyes open, some parts of the brain stem are probably functioning. Doctors sometimes use a standardized scoring system, such as the Glasgow Coma Scale, to help track changes in a person's level of consciousness. This scale assigns points based on responses to stimuli. Eye movement, speech, and movements are evaluated. This scale is a relatively reliable, objective measure of how unresponsive people are. Abnormal breathing patternscan provide clues to which parts of the brain are malfunctioning. Checkingresponses to painful stimulationcan help determine whether parts of the brain and spinal cord are malfunctioning. When coma is present, using painful stimuli may trigger unusual body positions. For example, the head may be tilted back with the arms and legs extended (called decerebrate rigidity). Or the arms may be flexed with both legs extended (called decorticate rigidity). This test helps identify the area of the brain that is not functioning normally. Limpness of the entire body and no movements in response to pain are the worst possible response. They indicate severe dysfunction in the central nervous system (brain and spinal cord). However, if muscle tone and movements return, the cause may be a reversible one, such as a sedative overdose. Automatic Reflexes None All automatic reflexes are normal if unresponsiveness is caused by a psychiatric disorder that does not impair consciousness. Theeyesalso provide important clues about how well the brain stem is functioning and what may be impairing consciousness. Doctors check the position of the pupils, their size, their reaction to bright light, their ability to follow a moving object (in people who are alert and awake), and the appearance of the retina. Normally, pupils widen (dilate) when light is dim and become smaller (constrict) when light is shined on them. However, the pupils may not respond normally to light in people in a coma. How the pupils respond to light or whether they respond helps doctors determine the cause of the coma. To accurately evaluate the person, doctors need to know whether the person takes a drug to treat glaucoma, which can affect pupil size, and they usually need to know whether the person’s pupils are normally different sizes. Doctors also examine the inside of the eye with an Ophthalmoscopy for signs that the pressure within the skull is increased. If findings suggest that the pressure within the skull is increased, doctors do imaging tests immediately to check for swelling, bleeding, a structural abnormality that blocks the flow of cerebrospinal fluid, or a mass in the brain (such as a tumor, an accumulation of blood, or an abscess). If imaging test results indicate increased pressure, doctors may drill a small hole in the skull and insert a device into one of the fluid-filled spaces (ventricles) in the brain. This device is used to reduce the pressure and monitor it during treatment. Theperson’s response to certain maneuverscan help doctors determine whether the brain stem is functioning normally: Rotating the head and observing eye movements. If the person is unconscious, gently flushing ice-cold water into one ear, then the other ear and observing eye movements (called caloric testing) Caloric testing is done only if people are unconscious and doctors cannot check eye movements any other way. If people are conscious, flushing ice-cold water into their ear can cause severe Dizziness and Vertigo , nausea, and vomiting. These tests provide further clues about the possible cause of stupor or coma. Blood levels of substances including sugar, electrolytes (such as sodium), alcohol, oxygen, minerals (such as magnesium), and carbon dioxide are measured. High levels of carbon dioxide may indicate that the person's breathing is impaired and that mechanical ventilation is required. Red and white blood cell counts are determined. Blood tests to check liver function and kidney function are done. Urine is analyzed to determine whether any commonly used or suspected toxic substances are present. Samples of blood and urine may be sent to a laboratory to be cultured (to grow any microorganisms present) to check for infections. Doctors measure the oxygen level in blood with a sensor placed on a finger (called pulse oximetry). They also measure levels of oxygen, carbon dioxide, and sometimes other gases in a sample of blood withdrawn from an artery (arterial blood gas tests). These tests are done to check for heart and lung disorders. Other laboratory tests may be done, depending on which causes of coma doctors suspect. Electrocardiography (ECG) is done to check for heart disorders, which may reduce blood flow to the brain. Chest x-ray may be done to check for lung disorders, which may reduce the amount of oxygen in the blood. If no cause has been quickly identified, computed tomography (CT) or magnetic resonance imaging (MRI) of the head is done to check for a mass, bleeding, swelling, or other structural brain damage. If the cause is unclear after imaging tests or if meningitis or bleeding between the layers of tissue covering the brain ( Subarachnoid Hemorrhage (SAH) ) is possible, a If doctors suspect the cause of impaired consciousness is seizures or if the cause is unclear after other tests are done, Electroencephalography (EEG) may be done to check the brain’s electrical activity, which may be abnormal if the brain is not functioning normally. Occasionally, EEG indicates that the person is having seizures even though the limbs are not jerking (a disorder called 