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Altered Mental Status and Coma
Brian Nelson
Case No. 1
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A 21 yo BF presents to the Baltimore City
Hospital E.D. in the summer of ‘78.
Her family states she is having a bad
headache and needs her “Quiet World”
tablets
Case continues
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No history other than an Ambulance took
her to another hospital earlier that day when
a neighbor heard her screaming and called
EMS
At the other hospital an exam and CBC
were said to be normal and she was
discharged
General Exam
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Patient grossly delirious, oriented to name
only
BP 125/70, P 76, RR 24, T 100.2 orally
HEENT: PERRL, fundi difficult to evauate
because of roaming eyes, grossly normal
Neck: Very Stiff
Chest: Loud wet rales throughout lung
fields
Neurologic Exam
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Able to follow only simplest comands,
Cranial Nerves grossly intact, Cerebellar
could not be tested, specific muslce group
strength could not be tested, but patient
moved all extremities and fought attempts
to test range of motion. Reflexes, gait and
Romberg could not be tested
Diagnostic workup
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CXR: Complete opacification of left lung
CBC: Hct 43, WBC 10.7 K, 75 segs, 17
bands, 7 lymphs
ABGs on room air: 7.42/37/98
Lytes, BUN, glucose, Ca, PO4 all normal
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Provisional Diagnosis?
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Diagnosis and Dilemma
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Provisonal Diagnosis: Pneumococcal
Pneumonia with secondary meningitis
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Plan? Allow that in 1978 the nearest CT
scanner was 5 miles away (and slow first
generation). Minimum time to get a head
CT 3 hours
LP was performed
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Opening pressure was 28 cm H2O
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5 cc clear spinal fluid removed
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5 minutes later the patient lost
consciousness, dilated her left pupil and
stopped breathing
Coma mnemonic for the brain
impaired Doc
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A for alcoholism
E for encephalopathy
I for insulin
O for opiates
U for uremia
T for trauma and environmental disturbance
I for infection
P for psychiatric
S for syncope
Alcoholics have many reasons to
be impaired
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Head trauma, hypothermia
Infections: pneumonia, meningitis, sepsis
Withdrawal: delerium tremens, post-ictal
Metabolic: alcoholic ketoacidosis, lactic acidosis
Brain atrophy, Wernicke’s, Korsakoff’s, lead
encephalopathy
Toxic alcohols: methanol, isopropyl, ethylene
glycol
Liver failure, hypoxia
E for encephalopathy
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Post-ictal
Hypertensive Encephalopathy
Intracerebral mass
CVA - vasocclusive
• thrombosis
• embolism
• venous infarct
CVA- hemorrhagic
• Intracerebral hemorrhage
• Subarachnoid hemorrhage
I for insulin
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Too little
• Diabetic Ketoacidosis
• Hyperosmolar Non-ketotic Coma
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Too much
• Hypoglycemia
O for opiates
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Essentially any chemical including water
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sedatives
anticholinergics
hallucinogens
sympathomimetics
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U for uremia
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Hyper and hypo Na, hyper and hypo Ca,
hyper and hypo Mg, hypophosphatemia
Hyper and hypo T4, Hyper and hypo
adrenal, panhypopituitarism
Liver, renal, and exocrine pancreas failure,
HYPERCARBIA
HYPOXIA, HYPOXIA, HYPOXIA
T for trauma and environmental
disturbance
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Epidural, Subdural, Subarachnoid and
intracerebral hemorrhage
Concussion and contusion
Hypo and hyperthermia
I for infection
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Meningitis
Sepsis
Brain abscess
Encephalitis
The weirdos: cerebral syphillis, malaria,
tuberculosis, cystocercosis, nagleria,
cryptococcosis, toxoplasmosis, etc
P for psychiatric
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Hysteria
Malingering
Catatonia
S is for syncope
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Arrhythmias
Infarction
Hypovolemia
Hemorrhage
Vasodepressor syncope
Causes of Stupor or Coma in 500
patients
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Diffuse dysfunction 76%
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Supratentorial lesions 20%
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Subtentorial lesions 12%
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Psychiatric 8%
Things that aren’t coma
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Dementia
Acute Confusional State (Delerium)
Persistent Vegetative State
Akinetic Mutism
Locked in syndrome
Psychogenic Unresponsiveness
Brain death
When altered but not Coma, check
components of consciousness
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Wakefulness
Attention
Working Memory
Perception
Long-term Memory
Motivation
Cognition
Purposeful motor response
Initial actions
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Check SaO2 and pupils, support respiration
and oxygenation, Narcan for suspected
narcotics OD
Check BP and conjunctiva, treat shock and
anemia
Glucometer, admin glucose if indicated
Two minute exam, Is it
structural?
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History
Pupillary reactions
Oculocaloric respones
Respiratory pattern
Motor responses
Skeletal tone
Should have 95% accuracy of structural vs
diffuse dysfunction
Is it structural: History
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Sudden vs. gradual onset
PMH: particulary depression, Diabetes,
Drug user, medications prescribed or
missing
Is it structural: pupillary
reactions
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Metabolic: small reactive
Diencephalic: small reactive
Midbrain: midposition, fixed
CN III: unilateral dilated
Pons: pinpoint fixed
Medulla: dilated, fixed
Tox: narcotics -pinpoint reactive, hypoxic,
barbs - dilated and fixed
Oculocalorics
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Brainstem intact: deviates to cold water
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Brainstem damaged: anything else
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Low brainstem: no response
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COWS is backwards, patient must have live
vestibule, no vestibular toxic drugs
Respiratory Pattern
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Eupnea: diffuse dysfunction
Cheynes-Stokes: Diencephalon
Sustained hyperventilation: Midbrain
Ataxic: Medullary
Motor Responses and tone
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Diffuse: aversive reactions
Early diencephalon: aversive &
cogwheeling
Low diencephalon: flaccid or decorticate,
tone decreased
Midbrain: flaccid or decerebrate
Medulla: lower extremity flexion
Diffuse dysfunction
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Pupils small and reactive
Oculocalorics: tonic deviation
Tone: normal
No posturing, normal tone
Normal breathing of Cheyne-Stokes
Psychogenic unresponsiveness
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Eyelids flutter and close actively
Pupils small and reactive
Tone variable, bizarre posturing may be
present
Optokinetic testing positive
Oculocalorics: fast component present
Supratentorial Mass
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Initially focal signs (the mass)
Signs move rostral to caudal
Signs point to one level at any time
motor signs may be asymmetrical
Supratentorial herniation
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Central
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Uncal
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Combined
Early diencephalic phase
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Eupnea
Pupils small and reactive
conjugate deviation
aversive motions
cogwheeling (paratonia)
Late diencephalic
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Cheyne-Stokes breathing
Pupils small and reactive
Conjugate deviation: easier less cortical
control
Flaccid or decorticate
Mid-brain upper pons
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Sustained hyperventilation
pupils mid position, fixed irregular
oculocalorics impaired, dysconjugate
flaccid or decerbrate
Lower pons, upper medulla
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Ataxic breathing
pupils midposition fixed irregular
No caloric response
flaccid or L.E. flexion
Uncal herniation - early 3rd
nerve
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Eupneic
Dilate pupil, sluggish
full or dysconjugate oculocalorics
aversive movements, paratonia,
Patient may be awake
Uncal herniation Late 3rd nerve
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Sustained hyperventilation
Dilated pupil, lid droops,
Eye moves out and down
Decorticate posturing
Subtentorial lesions
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Pontine hemorrhage or infarction
 Tumors
 Cerebellar hemorrhage: if treated surgically
before coma ensues, patient may achieve normal
neurolgic recovery
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Signs point to one level and stay there
 Cranial nerve findings common
 Vertigo and nystagmus often prominent
Initial diagnostic eval: all
patients
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Lytes, BUN, Glucose
Measured osmolality
ABGs and cooximetry
Urinalysis
Selected studies for some patients
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Imaging
LP
Endocrine, Liver function
Cultures (blood, CSF)
Toxicology
ECG
Management
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Oxygen, ventilation, airway protection
Circulation
Glucose and thiamine, narcan
lower intercranial pressure
Control seizures
Treat infection
Correct acid-base disturbances
Management
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Correct electrolytes
Correct body temperature
Specific antidotes
Control agitation
Oh yes, and our herniating lady
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Patient was intubated and hyperventilated
Mannitol was given
Neurosurgeon was paged stat
He placed an intraventricular drain, clear
CSF squirted across the room. . .
And she woke up
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Patient was taken to angio suite where a 4
vessel revealed bilaterally greatly enlarged
ventricles
Dye down the drain revealed a noncommunicating hydrocephalus with block
below the 4th ventricle
Subsequent records from the warehouse
revealed that she had been admitted for 6
months at age 18 months
DX: Hydrocephalus residual
from TB meningitis 18 yrs before
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Patient was given a Ventriculo-peritoneal
shunt, was doing well 6 months later
Lessons
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Her neck wasn’t stiff and she wasn’t
resisting ROM, she had paratonia
She had no focal findings because the
lesions were bilateral and symmetrical
Neurosurgeons are handy
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It’s better to be lucky than good
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Case 2
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37 yo M found down at place of business at 5 am
 On arrival to ED: Tachypneic, tachycardic,
hypertensive, diaphoretic and retching.
Unresponsive to voice or pain. Pupils 2 mm
bilaterally and unresponsive to light. Does not
move extremities.
 Pt paralyzed, intubated and sedated
 What are the possible diagnoses? How should we
work it up?
Case 2 possible Diagnoses
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Mixed overdose with narcotic effect pupils
possible but unlikely: narcan had no effect
Intracerebral hemorrhage with
intraventricular extension leading to sudden
central herniation
Primary pontine lesion, if onset were
sudden, more likely a bleed than a stroke