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Neurocritical Care, Coma, and Disorders of Consciousness

Manual: General · Subject: Neurology

Synthesize the management of coma, brain injury, increased intracranial pressure, and quantitative bedside and laboratory assessment of consciousness.

The ICU Brain

Coma as Global Brain Dysfunction

Coma reflects failure of the ascending arousal system, bilateral hemispheric function, or both. Causes include structural injury, metabolic derangement, intoxication, infection, seizures, and post-anoxic injury.

Major Causes of Altered Consciousness

Structural

  • Mass lesions, hemorrhage, hydrocephalus, herniation
  • May produce focal signs or asymmetry
  • Often require emergent neuroimaging

Nonstructural

  • Metabolic, toxic, infectious, epileptic, inflammatory causes
  • Often diffuse and potentially reversible
  • Require rapid laboratory and physiologic evaluation

Neurocritical Concepts

Intracranial pressure
Pressure within the cranial vault that influences cerebral perfusion
Cerebral perfusion pressure
Approximate driving pressure for cerebral blood flow
Herniation
Pathologic shift of brain tissue across rigid compartments
Secondary brain injury
Delayed damage from hypoxia, hypotension, edema, excitotoxicity, or inflammation

Which finding is most concerning for impending transtentorial herniation?

What is the main danger of delayed recognition of nonconvulsive status epilepticus in coma?

Coma Evaluation Sequence

  1. 1

    Step 1: Stabilize airway, breathing, circulation, and glucose.

  2. 2

    Step 2: Perform a focused neurologic exam for lateralizing signs and brainstem reflexes.

  3. 3

    Step 3: Obtain emergent imaging and key metabolic, toxic, and infectious tests.

  4. 4

    Step 4: Use EEG when seizure or nonconvulsive status is possible.

  5. 5

    Step 5: Treat reversible causes while preventing secondary brain injury.

Which condition is most likely to produce diffuse, reversible encephalopathy?

Research Frontier

Modern neurocritical care increasingly uses multimodal monitoring, continuous EEG, advanced neuroimaging, and computational prediction of secondary injury to guide individualized therapy.