Plum and Posner's Diagnosis and Treatment of Stupor and Coma

Jerome B. Posner, MD is a Professor Emeritus at Cornell Medical College and former Chairman of Neurology at Memorial-Sloan Kettering Cancer center in New York. He graduated from the University of Washington before moving to Cornell University Medical College. He was appointed to the New York Genome Center in 2016. Dr Posner has held many leadership positions throughout his long and distinguished tenure at Weill Cornell and Memorial Sloan-Kettering Cancer Center, including being President of the American Neurological Association. He is a member of the National Academy of Medicine and served on the advisory council of the National Institute of Neurological Diseases and Stroke (NINDS).Clifford B. Saper, MD, PhD is the James Jackson Putnam Professor of Neurology and Neuroscience at Harvard Medical School and Chairman of Neurology at Beth Israel Deaconess Medical Center in Boston. He received his degrees, and did his internship in internal medicine, at Washington University School ofMedicine in St. Louis, before doing a neurology residency at Cornell University Medical Center- New York Hospital. He was previously on faculty at Washington University School of Medicine and the University of Chicago. Dr. Saper has received a Javits Neuroscience Investigator Award from the National Institutes of Health, and was elected to the National Academy of Medicine. He is the Editor-in-Chief of the Annals of Neurology. Nicholas D. Schiff, MD is the Jerold B. Katz Professor of Neurology and Neuroscience in the Feil Family Brain and Mind Research Institute at Weill Cornell Medical College. He is a graduate of Stanford University and the Cornell University Medical College and completed his residency in Neurology at the New York Hospital where he trained with Drs. Fred Plum and Jerome Posner He is an elected Fellow of the American Neurological Association and the recipient of several awards, including the 2007 Research Award for Innovation in Neuroscience from the Society forNeuroscience and the 2009 Bakken Pioneer Award from the Earl and Doris Bakken Heart-Brain Institute.Jan Claassen, MD is an Associate Professor of Neurology at Columbia University and Director of the NeuroICU at New York-Presbyterian Hospital. He received a degree in medicine from the University of Hamburg. He underwent post-doctoral research training and clinical training in neurology, electrophysiology, and neurocritical care at Columbia University, NY. His research characterizes physiologic changes following acute brain injury, focusing on novel treatment approaches to potentially improve patient outcomes. His laboratory focuses on the development and bedside integration of novel electrophysiological and imaging techniques study recovery of consciousness in the acute brain injury setting. Dr Claassen has been intimately involved with national and international guideline development for patients with acute brain injury.

This is a great resource. It has been 12 years since the last edition and this edition was necessary to provide the most up-to-date information. (Weighted Numerical Score: 100 - 5 Stars!)

• 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 Humans 2. 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 Potentials 3. 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 BRAINSTEM 4. 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 MYELINOLYSIS 5. Metabolic and Diffuse Encephalopathies: Disruption of the Internal MilieuDISTINGUISHING FEATURES OF METABOLIC ENCEPHALOPATHY Mental status testing, delirium, and grading level of unresponsiveness Distinguishing metabolic encephalopathy from focal causes of coma Distinguishing 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 FUNCTION Cerebral blood flow, glucose, and oxygen utilization Acid-base balance and osmolality Ionic environment in the brain and spreading depression Synaptic environment in the brain and seizures DISORDERS OF THE INTERNAL MILIEU: LACK OF SUBSTRATE Cerebral hypoxia Hypoperfusion (global ischemia, multifocal vascular compromise) Hypoglycemia Lack of metabolic cofactors (thiamine) Mitochondrial disordersDISORDERS OF THE INTERNAL MILIEU: IONIC AND OSMOTIC ENVIRONMENT Hyponatremia Hypernatremia Hypercalcemia Metabolic acidosis Hyperglycemia, hyperosmolar state Hypo-osmolar state DISORDERS OF THE INTERNAL MILIEU: HORMONAL AND TEMPERATURE Hypothyroidism Hyperthyroidism Adrenal insufficiency Hypothermia Hyperthermia DISORDERS OF THE INTERNAL MILIEU: ELECTRICAL ENVIRONMENT Seizure disorders Spreading depression DISORDERS OF THE INTERNAL MILIEU: ABNORMAL CSF PRESSURE OR CONSTITUENTS Intracranial hypertension Intracranial hypotension Subarachnoid hemorrhage Acute bacterial meningitis Chronic bacterial or fungal meningitis Viral meningitis vs. encephalitis Carcinomatous meningitisDISORDERS OF ENDOGENOUS TOXINS Hypercarbia Hepatic encephalopathy Renal failure Pancreatic encephalopathy Systemic septic encephalopathy Auto-immune disorders: specific antibodies Auto-immune disorders: acute disseminated encephalomyelitisDISORDERS OF EXOGENOUS TOXINS Sedative/hypnotic drugs and anesthetics (GABA-A receptor enhancers) Ethanol, methanol, and propylene glycol (including withdrawal) Ketamine, phencyclidine (NMDA receptor antagonists)Antidepressants Neuroleptics Opiates Aspirin and acetaminophen Overdose of unknown type 6. 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 CIRCULATION Ensure Oxygenation, Airway, and VentilationMaintain the CirculationHISTORY, EXAM, AND BASIC DIAGNOSTICS Emergency 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 Coma 8. 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 Stroke Venous Sinus ThrombosisBrain TumorBrain AbscessNONSTRUCTURAL LESIONS: METABOLIC, DIFFUSE, OR MULTIFOCAL COMACentral nervous system infectionsAutoimmune causes of comaHypoxic Brain Injury / cardiac arrestMetabolic coma GENERAL MANAGEMENT CONSIDERATIONS APPLYING TO ALL OR MOST BRAIN INJURED PATIENTS GOALS OF CAREFINAL WORD 9. Prognosis in Coma and Related Disorders of Consciousness andMechanisms Underlying Outcomes 10. Brain Death - Joseph J. FinsDETERMINATION OF BRAIN DEATHCLINICAL SIGNS OF BRAIN DEATH Brainstem 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