Description
Plum and Posner's Diagnosis and Treatment of Stupor and Coma, 5th edition, is a major update of the classic work on diagnosing the cause of coma, with the addition of completely new sections on treatment of comatose patients, by Dr. Jan Claassen, the Director of the Neuro-ICU at Columbia New York Presbyterian Hospital. The first chapter of the book provides an up-to-date review on the brain mechanisms that maintain a conscious state in humans, and how lesions that damage these mechanisms cause loss of consciousness or coma. The second chapter reviews the neurological examination of the comatose patient, which provides the basis for determining whether the patient is suffering from a structural brain injury causing the coma, or from a metabolic disorder of consciousness. The third and fourth chapters review the pathophysiology of structural lesions causing coma, and the specific disease states that result in coma. Chapter five is a comprehensive treatment of the many causes of metabolic coma. Chapter 6 review psychiatric causes of unresponsiveness and how to identify and treat them. Chapters 7 and 8 review the overall emergency treatment of comatose patients, followed by the treatment of specific causes of coma. Chapter 9 examines the long term outcomes of coma, including the minimally conscious state and the persistent vegetative state, and how they can be distinguished, and their implications for eventual useful recovery. Chapter 10 reviews the topic of brain death and the standards for examination of a patient that are required to make the determination of brain death. The final chapter 11 is by J.J. Fins, a medical ethicist who was invited by the other authors to write an essay on the ethics of diagnosis and treatment of patients who, by definition, have no way to approve of or communicate about their wishes.While providing detailed background for neurological and neurosurgical specialists, the practical nature of the material in this book has found its greatest use among Internists, Emergency Medicine, and Intensive Care specialists, who deal with comatose patients frequently, but who may not have had extensive neurological training.
Table of Contents
1. Pathophysiology of Signs and Symptoms of ComaALTERED STATES OF CONSCIOUSNESSDEFINITIONSConsciousnessAcutely Altered States of ConsciousnessSubacute or Chronic Alterations of ConsciousnessAPPROACH TO THE DIAGNOSIS OF THE COMATOSE PATIENTPHYSIOLOGY AND PATHOPHYSIOLOGY OF CONSCIOUSNESS AND COMAThe Ascending Arousal SystemBehavioral State SwitchingRelationship of Coma to SleepThe Cerebral Hemispheres and Conscious BehaviorStructural Lesions That Cause Altered Consciousness in Humans2. Examination of the Comatose PatientOVERVIEWHISTORYGENERAL PHYSICAL EXAMINATIONLEVEL OF CONSCIOUSNESSABC: AIRWAY, BREATHING,CIRCULATIONCirculationRespirationPUPILLARY RESPONSESExamine the Pupils and Their ResponsesPathophysiology of Pupillary Responses:Peripheral Anatomy of the Pupillomotor SystemPharmacology of the Peripheral Pupillomotor SystemLocalizing Value of Abnormal Pupillary Responses in Patients in ComaMetabolic and Pharmacologic Causes of Abnormal Pupillary ResponseOCULOMOTOR RESPONSESFunctional Anatomy of the Peripheral Oculomotor SystemFunctional Anatomy of the Central Oculomotor SystemThe Ocular Motor ExaminationInterpretation of Abnormal Ocular MovementsMOTOR RESPONSESMotor ToneMotor ReflexesMotor ResponsesFALSE LOCALIZING SIGNS IN PATIENTS WITH METABOLIC COMARespiratory ResponsesPupillary ResponsesOcular Motor ResponsesMotor ResponsesMAJOR LABORATORY DIAGNOSTIC AIDSBlood and Urine TestingComputed Tomography Imaging and AngiographyMagnetic Resonance Imaging and AngiographyMagnetic Resonance SpectroscopyNeurosonographyLumbar PunctureElectroencephalography and Evoked Potentials3. Structural Causes of Stupor and ComaCOMPRESSIVE LESIONS AS A CAUSE OF COMACOMPRESSIVE LESIONS MAY DIRECTLY DISTORT THE AROUSAL SYSTEMCompression at Different Levels of the Central Nervous System Presents in Distinct WaysThe Role of Increased Intracranial Pressure in ComaThe Role of Vascular Factors and Cerebral Edema in Mass LesionsHERNIATION SYNDROMES: INTRACRANIAL SHIFTS IN THE PATHOGENESIS OF COMAAnatomy of the Intracranial CompartmentsPatterns of Brain Shifts That Contribute to ComaClinical Findings in Uncal Herniation SyndromeClinical Findings in Central Herniation SyndromeClinical Findings in Dorsal Midbrain SyndromeSafety of Lumbar Puncture in Comatose PatientsFalse Localizing Signs in the Diagnosis of Structural ComaDESTRUCTIVE LESIONS AS A CAUSE OF COMADIFFUSE, BILATERAL CORTICAL DESTRUCTIONDESTRUCTIVE DISEASE OF THE DIENCEPHALONDESTRUCTIVE LESIONS OF THE BRAINSTEM4. Specific Causes of Stupor and ComaINTRODUCTIONSUPRATENTORIAL COMPRESSIVE LESIONSEPIDURAL, DURAL, AND SUBDURAL MASSESEpidural HematomaSubdural HematomaEpidural Abscess/EmpyemaDural and Subdural TumorsSUBARACHNOID LESIONSSubarachnoid HemorrhageSubarachnoid TumorsSubarachnoid InfectionINTRACEREBRAL MASSESIntracerebral HemorrhageIntracerebral TumorsBrain Abscess and GranulomaINFRATENTORIAL COMPRESSIVE ESIONSEPIDURAL AND DURAL MASSESEpidural HematomaEpidural AbscessDural and Epidural TumorsSUBDURAL POSTERIOR FOSSA OMPRESSIVE LESIONSSubdural EmpyemaSubdural TumorsSUBARACHNOID POSTERIOR FOSSA LESIONSINTRAPARENCHYMAL POSTERIOR FOSSA MASS LESIONSCerebellar HemorrhageCerebellar InfarctionCerebellar AbscessCerebellar TumorPontine HemorrhageSUPRATENTORIAL DESTRUCTIVE LESIONS CAUSING COMAVASCULAR CAUSES OF SUPRATENTORIAL DESTRUCTIVE LESIONSCarotid Ischemic LesionsDistal Basilar OcclusionVenous Sinus ThrombosisVasculitisINFECTIONS AND INFLAMMATORY CAUSES OF SUPRATENTORIAL DESTRUCTIVE LESIONSViral EncephalitisAcute Disseminated EncephalomyelitisCONCUSSION AND OTHER TRAUMATIC BRAIN INJURIESMechanism of Brain Injury During Closed Head TraumaMechanism of Loss of Consciousness in ConcussionDelayed Encephalopathy After Head InjuryINFRATENTORIAL DESTRUCTIVE LESIONSBRAINSTEM VASCULAR DESTRUCTIVE DISORDERSBrainstem HemorrhageBasilar MigrainePosterior Reversible Leukoencephalopathy SyndromeINFRATENTORIAL INFLAMMATORY DISORDERSINFRATENTORIAL TUMORSCENTRAL PONTINE MYELINOLYSIS5. Metabolic and Diffuse Encephalopathies: Disruption of the Internal MilieuDISTINGUISHING FEATURES OF METABOLIC ENCEPHALOPATHYMental status testing, delirium, and grading level of unresponsivenessDistinguishing metabolic encephalopathy from focal causes of comaDistinguishing metabolic encephalopathy from diffuse or multifocal causes of comaKey features of the neurological exam in metabolic encephalopathyTHE INTERNAL MILIEU: AN OVERVIEW OF CEREBRAL METABOLISM AND THE ENVIRONMENT NECESSARY TO MAINTAIN NORMAL NEURONAL FUNCTIONCerebral blood flow, glucose, and oxygen utilizationAcid-base balance and osmolalityIonic environment in the brain and spreading depressionSynaptic environment in the brain and seizuresDISORDERS OF THE INTERNAL MILIEU: LACK OF SUBSTRATECerebral hypoxiaHypoperfusion (global ischemia, multifocal vascular compromise)HypoglycemiaLack of metabolic cofactors (thiamine)Mitochondrial disordersDISORDERS OF THE INTERNAL MILIEU: IONIC AND OSMOTIC ENVIRONMENTHyponatremiaHypernatremiaHypercalcemiaMetabolic acidosisHyperglycemia, hyperosmolar stateHypo-osmolar stateDISORDERS OF THE INTERNAL MILIEU: HORMONAL AND TEMPERATUREHypothyroidismHyperthyroidismAdrenal insufficiencyHypothermiaHyperthermiaDISORDERS OF THE INTERNAL MILIEU: ELECTRICAL ENVIRONMENTSeizure disordersSpreading depressionDISORDERS OF THE INTERNAL MILIEU: ABNORMAL CSF PRESSURE OR CONSTITUENTSIntracranial hypertensionIntracranial hypotensionSubarachnoid hemorrhageAcute bacterial meningitisChronic bacterial or fungal meningitisViral meningitis vs. encephalitisCarcinomatous meningitisDISORDERS OF ENDOGENOUS TOXINSHypercarbiaHepatic encephalopathyRenal failurePancreatic encephalopathySystemic septic encephalopathyAuto-immune disorders: specific antibodiesAuto-immune disorders: acute disseminated encephalomyelitisDISORDERS OF EXOGENOUS TOXINSSedative/hypnotic drugs and anesthetics (GABA-A receptor enhancers)Ethanol, methanol, and propylene glycol (including withdrawal)Ketamine, phencyclidine (NMDA receptor antagonists)AntidepressantsNeurolepticsOpiatesAspirin and acetaminophenOverdose of unknown type6. Psychogenic UnresponsivenessCONVERSION REACTIONSCATATONIAPSYCHOGENIC SEIZURESCEREBELLAR COGNITIVE AFFECTIVE SYNDROME''AMYTAL INTERVIEW''7. Approach to Management of the Unconscious PatientA CLINICAL REGIMEN FOR DIAGNOSIS AND MANAGEMENTALGORITHM AND PRINCIPLES OF EMERGENCY MANAGEMENTSUPPORT VITAL SIGNS: AIRWAY, BREATHING, AND CIRCULATIONEnsure Oxygenation, Airway, and VentilationMaintain the CirculationHISTORY, EXAM, AND BASIC DIAGNOSTICSEmergency Examination of the Comatose and Stuperous PatientEmergent Treatment that Should be Considered for All Patients with Stupor or ComaMore Definitive Treatment of Etiologies of Stupor and Coma8. Management of Frequently Encountered Causes of UnconsciousnessMANAGEMENT OF FREQUENTLY ENCOUNTERED CAUSES OF UNCONSCIOUSNESSSTRUCTURAL LESIONS: SUPRATENTORIAL OR INFRATENTORIAL COMPRESSIVE/DESTRUCTIVE ETIOLOGIESAneurysmal Subarachnoid HemorrhageIntracerebral HemorrhageTraumatic Brain InjurySubdural and Epidural HematomaArterial Ischemic StrokeVenous Sinus ThrombosisBrain TumorBrain AbscessNONSTRUCTURAL LESIONS: METABOLIC, DIFFUSE, OR MULTIFOCAL COMACentral nervous system infectionsAutoimmune causes of comaHypoxic Brain Injury / cardiac arrestMetabolic comaGENERAL MANAGEMENT CONSIDERATIONS APPLYING TO ALL OR MOST BRAIN INJURED PATIENTSGOALS OF CAREFINAL WORD9. Prognosis in Coma and Related Disorders of Consciousness andMechanisms Underlying Outcomes10. Brain Death - Joseph J. FinsDETERMINATION OF BRAIN DEATHCLINICAL SIGNS OF BRAIN DEATHBrainstem FunctionConfirmatory Laboratory Tests and DiagnosisDiagnosis of Brain Death in Profound Anesthesia or Coma of Undetermined EtiologyPitfalls in the Diagnosis of Brain DeathBrain Death versus Prolonged ComaManagement of the brain dead patient
