Third is the presence or absence of focality of the disorder, both in terms of the level of dysfunction within the rostrocaudal neuraxis and specific involvement of cortical or brainstem structures.Īfter the physician makes sure that no immediate life-threatening emergency such as airway obstruction or shock is present, the examination begins with observation of the patient. Second is evaluation of the patient, searching carefully for hints as to the cause of the confusion or coma.
The first is to determine the level of consciousness itself.
The technique of evaluation of the patient with an altered level of consciousness can be divided into three phases. The grade IV patient reacts inappropriately with either decorticate or decerebrate posturing to such deeply painful stimuli, and the grade V patient remains flaccid when similarly stimulated. The grade III patient is comatose but will ward off deeply painful stimuli such as sternal pressure or nipple twist with an appropriate response. The grade II patient requires a light pain stimulus (such as a sharp pin tapped lightly over the chest wall) for appropriate arousal, or may be combative or belligerent. The grade I patient is only slightly confused. It has been used for more than 10 years at Grady Memorial Hospital in Atlanta, Georgia, to gauge the level of consciousness of patients in the neurosurgical intensive care unit and elsewhere. The Grady Coma Scale ( Table 57.1) has proved functional in this regard. Scoring must be reproducible among observers. In order for such a scale to be useful it must be simple to learn, understand, and implement. This proves advantageous for several reasons: Communication among health care personnel about the neurologic condition of a patient is improved guidelines for diagnostic and therapeutic intervention in certain situations can be linked to the level of consciousness and in some situations a rough estimate of prognosis can be made based partly on the scale score.
It is helpful to have a standard scale by which one can measure levels of consciousness. Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state.Ĭoma is a state of unarousable unresponsiveness. Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states. Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep. Nevertheless, it is appropriate to define several of the terms as closely as possible.Ĭlouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness.Ĭonfusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands. Many of these terms mean different things to different people, and may prove inaccurate when transmitting and recording information regarding the state of consciousness of a patient. Among such terms are: clouding of consciousness, confusional state, delirium, lethargy, obtundation, stupor, dementia, hypersomnia, vegetative state, akinetic mutism, locked-in syndrome, coma, and brain death. The abnormal state of consciousness is more difficult to define and characterize, as evidenced by the many terms applied to altered states of consciousness by various observers. The normal state of consciousness comprises either the state of wakefulness, awareness, or alertness in which most human beings function while not asleep or one of the recognized stages of normal sleep from which the person can be readily awakened.
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