by Alberto J. Muniagurria and Eduardo Baravalle
Although the terms of inattention, confusion, coma, stupor and sleep are classic, it is more practical to detail the clinical findings of the patient and not use these terms, to define his level of consciousness.
Consciousness can be defined in physiological and / or psychological terms. From the physiological point of view it is possible to define the different levels of consciousness, as well as their content.
Different experiences and emotions reside in anatomically specific sites in the brain.
Confusion is a disorder in the content of consciousness. In contrast, alertness is maintained by thalamic neurons, the activating reticular system, and cortical connections.
Therefore, the depression of these structures can alter the alert state, preventing the evaluation of the content of consciousness.
Sleep . Sleep is a physiological period of physical and mental inactivity from which it is possible to wake up and go into alertness. There are individual and age variations; the child sleeps more and the elderly person less. They usually sleep 7.5 hours a day on average, with a normal variation of 4 to 10 hours. The person who sleeps responds to certain stimuli and sometimes has dreams as a manifestation of certain brain activity, which are sometimes remembered.
Sleep disturbances can be: 1) decrease and insomnia; 2) increase or hypersomnia; and 3) sleep disorders that do not affect its duration.
Inattention and confusion . When the patient does not take into account all the elements of the environment, we speak of inattention. The inattentive patient has impaired ability to concentrate his attention.
It is the first level of abnormality of consciousness. If it goes deep it becomes confusion.
The terms confusion and delusion are misused when taken synonymously. It is true that the delusional patient (with hallucinations and agitation) is confused, and has in common with the inattentive or confused patient the fact that there is always an element of imperception and distraction of attention. In contrast, the confused patient only shows alterations in the speed and coherence of his thought, without presenting hallucinations. The relationship between inattention, confusion, stupor and coma is evident; the patient can go through all these states, either when entering a coma or when leaving it.
In inattentive patients, with minimal confusion, the disorder may go unrecognized if conversation and behavior are not carefully explored. In moderate degrees of confusion, thinking is slow and incoherent; these patients jump from topic to topic and can converse for a few minutes. In severe degrees of confusion, patients can only respond to a few simple commands and are characterized by extreme poverty of their thinking, speaking with few words.
Estupor. Los pacientes estuporosos se caracterizan por presentar: 1) actividad mental y física reducidas al extremo; 2) no pueden responder a órdenes o sólo lo hacen con monosílabos y lentamente; 3) no muestran alteraciones en los reflejos tendinosos ni plantares. Por otra parte, es frecuente observar “grasping" y reflejos de succión, actividad motriz estereotipada y movimientos temblorosos.
Eat . The comatose patient is one who is not able to respond adequately to external or internal stimuli, with complete loss of consciousness. Tendon, plantar, and pupillary reflexes are usually absent. The respiratory rate is generally slowed or increased, and there may be alterations in the respiratory rhythm. There are varying degrees of coma. In the most superficial commas some reflections are preserved.
To determine the degree or extent of coma or loss of consciousness, there are various assessment systems, including the Glasgow scale.
The Glasgow scale is calculated with a score given to eye opening, verbal response, and motor response. The most critical patient will have the lowest result (Table 14-1).
|Table 14-1. Glasgow scale|
|To the voice||3|
|Motor response||Obey orders||6|
|Locate the pain||5|
|Withdraw for the pain||4|
|Flex in pain||3|
|Spread for the pain||two|
This scale of values (maximum 15, minimum 3) has prognostic significance, with a good correlation between the lowest figures and the worst forecasts. Thus, for example, the lowest number is 3 and indicates a poor prognosis, while the highest number is 15 and corresponds to the state of lucidity. Despite the fact that the same summation figure can reveal different states of consciousness, statistically it represents the same degree of prognostic probability.
For newborns there is an evaluation system called the Apgar test. The newborn is evaluated one minute after birth for heart rate, respiratory rate, muscle tone, reflexes, and color (Table 4-2). Each of the respective signs has a value from 0 to 2. The final result is between 1 and 10.
Values from 7 to 10 indicate excellent clinical status; 4 to 6 correspond to a pathological newborn, whose conditions must be carefully monitored; and less than 3 are an indication of seriousness and require urgent resuscitation measures.
|Table 14-2 Apgar test|
|Heart rate||Not detected||Less than 100||Greater than 100|
|Muscular tone||Limp||Some flex||Very active|
|Colour||Cyanotic-pale||Pink trunk and / or cyanotic limbs||Normal|