Plum and Posner's Diagnosis of Stupor and Coma

by Jerome B. Posner M.D., Clifford B. Saper M.D., Nicholas Schiff M.D., Fred Plum M.D.

Overview

Delirium, stupor and coma are common clinical states that confront clinicians in almost every medical specialty. With appropriate diagnosis and treatment, coma can often be treated successfully. Conversely, delay in diagnosis and treatment may be lethal. This monograph provides an update on the clinical approach that was laid out in the previous 3 editions. It describes an approach for the physician at the bedside to diagnose and treat alterations of consciousness, based on pathophysiologic principles. The book begins with a description of the physiology of consciousness and the pathophysiology of disorders of consciousness. It continues with a description of the approach to a patient with a disorder of consciousness, emphasizing the bedside examination, but including the use of modern imaging techniques. The important structural and metabolic causes of coma are reviewed in detail. It then describes the emergency treatment, both medical and surgical, of patients with specific disorders of consciousness and their prognosis. New chapters describe the approach to the diagnosis of brain death and the clinical physiology of the vegetative state and minimally conscious state, as well as the ethics of dealing with such patients and their families. The book is aimed at medical students and residents, in fields from internal medicine and pediatrics to emergency medicine, surgery, neurology, neurosurgery, and psychiatry, who are likely to encounter patients with disordered states of consciousness. It includes historical background and basic neurophysiology that is important for those in the clinical neurosciences, but also lays out a practical approach to the comatose patient that is an important part of the repertoire of all clinicians who provide emergency care for patients with disorders of consciousness.

Product Details

ISBN-13:	9780199886531
Publisher:	Oxford University Press
Publication date:	06/11/2007
Series:	Contemporary Neurology Series , #71
Sold by:	Barnes & Noble
Format:	eBook
File size:	13 MB
Note:	This product may take a few minutes to download.

About the Author

Memorial Sloan Kettering Cancer Center

Beth Israel Deaconess Hospital and Harvard Medical School

Weill Cornell Medical College

Cornell University

Table of Contents

Pathophysiology of Signs and Symptoms of Coma     3
Altered States of Consciousness     3
Definitions     5
Consciousness
Acutely Altered States of Consciousness
Subacute or Chronic Alterations of Consciousness
Approach to the Diagnosis of the Comatose Patient     9
Physiology and Pathophysiology of Consciousness and Coma     11
The Ascending Arousal System
Behavioral State Switching
Relationship of Coma to Sleep
The Cerebral Hemispheres and Conscious Behavior
Structural Lesions That Cause Altered Consciousness in Humans
Examination of the Comatose Patient     38
Overview     38
History     39
General Physical Examination     40
Level of Consciousness     40
ABC: Airway, Breathing, Circulation     42
Circulation
Respiration
Pupillary Responses     54
Examine the Pupils and Their Responses
Pathophysiology of Pupillary Responses: Peripheral Anatomy of the Pupillomotor System
Pharmacology of the Peripheral Pupillomotor System
Localizing Value of Abnormal Pupillary Responses in Patients in Coma
Metabolic and Pharmacologic Causes of Abnormal Pupillary Response
Oculomotor Responses     60
Functional Anatomy of the Peripheral Oculomotor System
Functional Anatomy of the Central Oculomotor System
The Ocular Motor Examination
Interpretation of Abnormal Ocular Movements
MotorResponses     72
Motor Tone
Motor Reflexes
Motor Responses
False Localizing Signs in Patients with Metabolic Coma     75
Respiratory Responses
Pupillary Responses
Ocular Motor Responses
Motor Responses
Major Laboratory Diagnostic Aids     77
Blood and Urine Testing
Computed Tomography Imaging and Angiography
Magnetic Resonance Imaging and Angiography
Magnetic Resonance Spectroscopy
Neurosonography
Lumbar Puncture
Electroencephalography and Evoked Potentials
Structural Causes of Stupor and Coma     88
Compressive Lesions as a Cause of Coma     89
Compressive Lesions May Directly Distort the Arousal System     90
Compression at Different Levels of the Central Nervous System Presents in Distinct Ways
The Role of Increased Intracranial Pressure in Coma
The Role of Vascular Factors and Cerebral Edema in Mass Lesions
Herniation Syndromes: Intracranial Shifts in the Pathogenesis of Coma     95
Anatomy of the Intracranial Compartments
Patterns of Brain Shifts That Contribute to Coma
Clinical Findings in Uncal Herniation Syndrome
Clinical Findings in Central Herniation Syndrome
Clinical Findings in Dorsal Midbrain Syndrome
Safety of Lumbar Puncture in Comatose Patients
False Localizing Signs in the Diagnosis of Structural Coma
Destructive Lesions as a Cause of Coma     114
Diffuse, Bilateral Cortical Destruction     114
Destructive Disease of the Diencephalon      114
Destructive Lesions of the Brainstem     115
Specific Causes of Structural Coma     119
Introduction     120
Supratentorial Compressive Lesions     120
Epidural, Dural, and Subdural Masses     120
Epidural Hematoma
Subdural Hematoma
Epidural Abscess/Empyema
Dural and Subdural Tumors
Subarachnoid Lesions     129
Subarachnoid Hemorrhage
Subarachnoid Tumors
Subarachnoid Infection
Intracerebral Masses     135
Intracerebral Hemorrhage
Intracerebral Tumors
Brain Abscess and Granuloma
Infratentorial Compressive Lesions     142
Epidural and Dural Masses     143
Epidural Hematoma
Epidural Abscess
Dural and Epidural Tumors
Subdural Posterior Fossa Compressive Lesions     144
Subdural Empyema
Subdural Tumors
Subarachnoid Posterior Fossa Lesions     145
Intraparenchymal Posterior Fossa Mass Lesions     145
Cerebellar Hemorrhage
Cerebellar Infarction
Cerebellar Abscess
Cerebellar Tumor
Pontine Hemorrhage
Supratentorial Destructive Lesions Causing Coma     151
Vascular Causes of Supratentorial Destructive Lesions     152
Carotid Ischemic Lesions
Distal Basilar Occlusion
Venous Sinus Thrombosis
Vasculitis
Infections and Inflammatory Causes of Supratentorial Destructive Lesions     156
Viral Encephalitis
Acute Disseminated Encephalomyelitis
Concussion and Other Traumatic Brain Injuries     159
Mechanism of Brain Injury During Closed Head Trauma
Mechanism of Loss of Consciousness in Concussion
Delayed Encephalopathy After Head Injury
Infratentorial Destructive Lesions     162
Brainstem Vascular Destructive Disorders     163
Brainstem Hemorrhage
Basilar Migraine
Posterior Reversible Leukoencephalopathy Syndrome
Infratentorial Inflammatory Disorders     169
Infratentorial Tumors     170
Central Pontine Myelinolysis     171
Multifocal, Diffuse, and Metabolic Brain Diseases Causing Delirium, Stupor, or Coma     179
Clinical Signs of Metabolic Encephalopathy     181
Consciousness: Clinical Aspects     181
Tests of Mental Status
Pathogenesis of the Mental Changes
Respiration     187
Neurologic Respiratory Changes Accompanying Metabolic Encephalopathy
Acid-Base Changes Accompanying Hyperventilation During Metabolic Encephalopathy
Acid-Base Changes Accompanying Hypoventilation During Metabolic Encephalopathy
Pupils     192
Ocular Motility     193
Motor Activity     194
"Nonspecific" Motor Abnormalities
Motor Abnormalities Characteristic of Metabolic Coma
Differential Diagnosis     197
Distinction Between Metabolic and Psychogenic Unresponsiveness
Distinction Between Coma of Metabolic and Structural Origin
Aspects of Cerebral Metabolism Pertinent to Coma     198
Cerebral Blood Flow     198
Glucose Metabolism     202
Hyperglycemia
Hypoglycemia
Anesthesia     205
Mechanisms of Irreversible Anoxic-Ischemic Brain Damage     206
Global Ischemia
Focal Ischemia
Hypoxia
Evaluation of Neurotransmitter Changes in Metabolic Coma     208
Acetylcholine
Dopamine
Gamma-Aminobutyric
Acid
Serotonin
Histamine
Glutamate
Norepinephrine
Specific Causes of Metabolic Coma     210
Ischemia and Hypoxia     210
Acute, Diffuse (or Global) Hypoxia or Ischemia
Intermittent or Sustained Hypoxia
Sequelae of Hypoxia
Disorders of Glucose or Cofactor Availability     220
Hypoglycemia
Hyperglycemia
Cofactor Deficiency
Diseases of Organ Systems Other than Brain     224
Liver Disease
Renal Disease
Pulmonary Disease
Pancreatic Encephalopathy
Diabetes Mellitus
Adrenal Disorders
Thyroid Disorders
Pituitary Disorders
Cancer
Exogenous Intoxications     240
Sedative and Psychotropic Drugs
Intoxication With Other Common Medications
Ethanol Intoxication
Intoxication With Drugs of Abuse
Intoxication With Drugs Causing Metabolic Acidosis
Abnormalities of Ionic or Acid-Base Environment of the Central Nervous System     251
Hypo-osmolar States
Hyperosmolar States
Calcium
Other Electrolytes
Disorders of Systemic Acid-Base Balance
Disorders of Thermoregulation     259
Hypothermia
Hyperthermia
Infectious Disorders of the Central Nervous System: Bacterial     262
Acute Bacterial Leptomeningitis
Chronic Bacterial Meningitis
Infectious Disorders of the Central Nervous System: Viral     266
Overview of Viral Encephalitis
Acute Viral Encephalitis
Acute Toxic Encephalopathy During Viral Encephalitis
Parainfectious Encephalitis (Acute Disseminated Encephalomyelitis)
Cerebral Biopsy for Diagnosis of Encephalitis
Cerebral Vasculitis and Other Vasculopathies     273
Granulomatous Central Nervous System Angiitis
Systemic Lupus Erythematosus
Subacute Diencephalic Angioencephalopathy
Varicella-Zoster Vasculitis
Behcet's Syndrome
Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy
Miscellaneous Neuronal and Glial Disorders     276
Prion Diseases
Adrenoleukodystrophy (Schilder's Disease)
Marchiafava-Bignami Disease
Gliomatosis Cerebri
Progressive Multifocal Leukoencephalopathy
Epilepsy
Mixed Metabolic Encephalopathy
Acute Delirious States     282
Drug Withdrawal Delirium (Delirium Tremens)
Postoperative Delirium
Intensive Care Unit Delirium
Drug-Induced Delirium
Psychogenic Unresponsiveness     297
Conversion Reactions     299
Catatonia     302
Psychogenic Seizures     304
Cerebellar Cognitive Affective Syndrome     306
"Amytal Interview"     307
Approach to Management of the Unconscious Patient     309
A Clinical Regimen for Diagnosis and Management     309
Principles of Emergency Management     311
Ensure Oxygenation, Airway, and Ventilation
Maintain the Circulation
Measure the Glucose
Lower the Intracranial Pressure
Stop Seizures
Treat Infection
Restore Acid-Base Balance
Adjust Body Temperature
Administer Specific Antidotes
Control Agitation
Protect the Eyes
Examination of the Patient     317
Verbal Responses
Respiratory Pattern
Eye Opening
Pupillary Reactions
Spontaneous Eye Movement
Oculocephalic Responses
Caloric Vestibulo-Ocular Responses
Corneal Responses
Motor Responses
Tendon Reflexes
Skeletal Muscle Tone
Guides to Specific Management     320
Supratentorial Mass Lesions
Infratentorial Mass Lesions
Metabolic Encephalopathy
Psychogenic Unresponsiveness
A Final Word     327
Brain Death     331
Determination of Brain Death     331
Clinical Signs of Brain Death     333
Brainstem Function
Confirmatory Laboratory Tests and Diagnosis
Diagnosis of Brain Death in Profound Anesthesia or Coma of Undetermined Etiology
Pitfalls in the Diagnosis of Brain Death
Prognosis in Coma and Related Disorders of Consciousness, Mechanisms Underlying Outcomes, and Ethical Considerations      341
Introduction     342
Prognosis in Coma     343
Prognosis by Disease State     344
Traumatic Brain Injury
Nontraumatic Coma
Vascular Disease
Central Nervous System Infection
Acute Disseminated Encephalomyelitis
Hepatic Coma
Depressant Drug Poisoning
Vegetative State     357
Clinical, Imaging, and Electrodiagnostic Correlates of Prognosis in the Vegetative State
Minimally Conscious State     360
Late Recoveries From the Minimally Conscious State
Locked in State     363
Mechanisms Underlying Outcomes of Severe Brain Injury: Neuroimaging Studies and Conceptual Frameworks     364
Functional Imaging of Vegetative State and Minimally Conscious State     365
Atypical Behavioral Features in the Persistent Vegetative State
Neuroimaging of Isolated Cortical Responses in Persistent Vegetative State Patients
Potential Mechanisms Underlying Residual Functional Capacity in Severely Disabled Patients     372
Variations of Structural Substrates Underlying Severe Disability
The Potential Role of the Metabolic "Baseline" in Recovery of Cognitive Function
The Potential Role of Regionally Selective Injuries Producing Widespread Effects on Brain Function
Ethics of Clinical Decision Making and Communication with Surrogates (J.J. Fins)     376
Surrogate Decision Making, Perceptions, and Needs
Professional Obligations and Diagnostic Discernment
Time-Delimited Prognostication and Evolving Brain States: Framing the Conversation
Family Dynamics and Philosophic Considerations
Index     387

Editorial Reviews

"The 4th edition is every bit as wonderful as the preceding 3, only with much more information...It is a wonderful clinical guide with clear descriptions of pathophysiology and application of modern technology for diagnosis."—Lewis P. Rowland, M.D., Columbia University Medical Center

"No book in any area of clinical neurology has paralleled the dominance of Plum and Posner. The Fourth Edition will sustain this preeminence and is a must for neurologists, neurosurgeons, intensivists, and emergency room physicians. We should all be grateful to the authors for presenting us with this updated gem."—Robert B. Daroff, MD, Department of Neurology, Case Western Reserve University, University Hospitals Case Medical Center

"Fred Plum and Jerome Posner wrote the first edition of The Diagnosis of Stupor and Coma to provide practical guidance and the current edition is an admirable and pleasing successor. On the basis of pedigree, coherence, and thoroughness, it is currently the last word on the subject."—New England Journal of Medicine

"Plum and Posner's book...exceeded those traditional territories and included the study of a wide range of endocrine and metabolic disorders...This is a great book and a fitting tribute to him who inspired it."—Brain

"Plum and Posners Diagnosis of Stupor and Coma is an essential text for the practicing neurologist, for the general intensivist or hospitalist, for the neurointensivist or neurosurgeon, and for the many students, residents, and fellows in the neurosciences. It stands the test of time, highlighting the legacy of Drs Plum and Posner, who have contributed so much to the field of neurology and to the training of generations of neurologists."—Wade Smith, Annals of Neurology

"This is an excellent text, and the substantial changes since the third edition easily justify the purchase of a new copy."—Doody's

"A necessity for all trainees involved in the care of the stuporous or comatose patient. This volume provides a clear framework from which to approach these clinical situations, and is highly recommended for neurosurgery residents and attendings alike."—Journal of Neurosurgery

"Over 50 years after its first edition, this book remains a gem among neurological monographs. Beyond maintaining a contemporary status, it has matured like good wine, improving over time to provide the reader with the best available summary of disorders of consciousness available on the market today...It belongs in every personal and institutional library."—European Neurology

"The book is a treasure trove of information, one of those books I will always be learning from...Everyone interested in the clinical aspects of disorders of consciousness should own a copy of this book."—Journal of Neurology, Neurosurgery, and Psychiatry

"The book is very readable and carefully arranged, and an appropriate index allows relevant content to be found quickly. The well-balanced selection of illustrations, including computed tomographic and magnetic resonance images, enriches the content and the graphics aid understanding...The fourth edition represents an excellent portrayal of the complex subject of consciousness disorders."—Archives of Neurology

"The 4th edition is every bit as wonderful as the preceding 3, only with much more information...It is a wonderful clinical guide with clear descriptions of pathophysiology and application of modern technology for diagnosis."—Lewis P. Rowland, M.D., Columbia University Medical Center

"No book in any area of clinical neurology has paralleled the dominance of Plum and Posner. The Fourth Edition will sustain this preeminence and is a must for neurologists, neurosurgeons, intensivists, and emergency room physicians. We should all be grateful to the authors for presenting us with this updated gem."—Robert B. Daroff, MD, Department of Neurology, Case Western Reserve University, University Hospitals Case Medical Center

"Fred Plum and Jerome Posner wrote the first edition of The Diagnosis of Stupor and Coma to provide practical guidance and the current edition is an admirable and pleasing successor. On the basis of pedigree, coherence, and thoroughness, it is currently the last word on the subject."—New England Journal of Medicine

"Plum and Posner's book...exceeded those traditional territories and included the study of a wide range of endocrine and metabolic disorders...This is a great book and a fitting tribute to him who inspired it."—Brain

"Plum and Posners Diagnosis of Stupor and Coma is an essential text for the practicing neurologist, for the general intensivist or hospitalist, for the neurointensivist or neurosurgeon, and for the many students, residents, and fellows in the neurosciences. It stands the test of time, highlighting the legacy of Drs Plum and Posner, who have contributed so much to the field of neurology and to the training of generations of neurologists."—Wade Smith, Annals of Neurology

"This is an excellent text, and the substantial changes since the third edition easily justify the purchase of a new copy."—Doody's

"A necessity for all trainees involved in the care of the stuporous or comatose patient. This volume provides a clear framework from which to approach these clinical situations, and is highly recommended for neurosurgery residents and attendings alike."—Journal of Neurosurgery

"Over 50 years after its first edition, this book remains a gem among neurological monographs...This book re-emphasizes the importance of neurology for proper diagnosis and management of stuporous or comatose patients. It belongs in every personal and institutional library."—European Neurology

"The book is a treasure trove of information, one of those books I will always be learning from...Everyone interested in the clinical aspects of disorders of consciousness should own a copy of this book."—Journal of Neurology, Neurosurgery, and Psychiatry

"The book is very readable and carefully arranged, and an appropriate index allows relevant content to be found quickly. The well-balanced selection of illustrations, including computed tomographic and magnetic resonance images, enriches the content and the graphics aid understanding...The fourth edition represents an excellent portrayal of the complex subject of consciousness disorders."—Archives of Neurology

"This text represents an extensive revision and update of a true classic in clinical neurology... this edition has been carefully edited to add relevant new data without altering the clinical feel of the prior work. The first three chapters alone provide adequate reason for this to be a 'must reference' available to all neurology residents and clinicians."—Neurology

From the Publisher

Reviewer: Bradley J. Robottom, MD (University of Maryland School of Medicine)
Description: This is a welcome update of a classic neurology text last revised in 1982 that focuses on the pathophysiology, etiology, and diagnosis of altered states of consciousness.
Purpose: The book offers a straightforward approach to the diagnosis and management of comatose patients. Despite the widespread availability of imaging modalities such as CT scan and MRI, the examination of the comatose patient remains the cornerstone of diagnosis and treatment. The book instructs readers how to evaluate the comatose patient in a comprehensive and timely fashion, allowing for prompt diagnosis and treatment.
Audience: Although written for neurologists, both residents in training and practicing physicians, those in other specialties, particularly those which deal with the emergent care of critically ill patients, would benefit from this book. The authors are recognized experts in the field, with the most senior authors, Plum and Posner, having written the first three editions.
Features: The book systematically addresses the pathophysiology underlying coma, the examination and diagnostic evaluation of the comatose patient, and the etiology and prognosis of coma. One chapter in particular, on the examination of the comatose patient, should be considered required reading for anyone completing a neurology residency. The authors' coverage of this topic is timeless and has changed little from earlier editions. One welcome feature of this edition is the presence of detailed, high quality images including MRI, SPECT imaging, CT perfusion scanning, and more.
Assessment: This is an excellent text, and the substantial changes since the third edition easily justify the purchase of a new copy.

Doody's Review Service