Coma

• sleep-like state from which pt can't be aroused
• unresponsive to ext stimuli/int needs
• reflex responses may be present

• alert
• lethargic: drowsy, may fall asleep
• delirium: disorientation, confusion
• obtunded: dec alertness, requires repeated stimulus to maintain consciousness
• stupor: conscious, but little or no spontaneous activity; only responds to strong noxious stimuli
• coma

suggest vascular origin (brainstem or subarachnoid hemorrhage)

suggests intracerebral hemorrhage

suggests tumor, abscess, or chronic subdural hematoma

suggests metabolic imbalance

pupils of both eyes constrict quickly and symmetrically

nonreactive to light; suggests CN III lesion

suggest midbrain lesion

suggests pontine lesion

suggests lesion to midbrain or CN III

assess oculomotor response to head movement

ice water poured into ear, normal response is nystagmus w/ fast phase to opposite sd; assess vestibulo-ocular response

• NOT a coma
• pontine infarction or other transection of brainstem below midbrain
• pt mute and quadriplegic but *preserved voluntary eye movements

• reactive pupils but other brainstem functions impaired
• can be caused by hypoglycemia, electrolyte imbalance, meningitis, subarachnoid hemorrhage, ischemia, hypo/hyperthermia

• younger age
• responsive pupils during first 24 hours
• normal response to caloric test in 24 hours
• signs of brainstem function
• higher GCS in first 24 hours
• shorter duration
• intensive rehab started earlier

• positioning/movement for prevention of pressure sores
• ROM for prevention of contractures
• vestibular stimulation and cardiovascular responses to movement
• interact as if pt conscious

• aimed at inc arousal
• inc auditory, visual, tactile, gustatory, olfactory, kinesthetic stimuli
• inc pt's purposeful responses
• pt needs to have stable vital signs before can begin and ICP below 15
• best to have quiet environment to promote selective attention