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{{About|the medical concept|the philosophical concept|Consciousness}}
{{Infobox symptom |
  Name          = Altered level of consciousness|
  Image          = Intracerebral heamorrage.jpg|
  Caption        = An [[intracranial hemorrhage]], one cause of altered level of consciousness|
  DiseasesDB    = |
  ICD10          = {{ICD10|R|40||r|40}} |
  ICD9          = {{ICD9|780.0}} |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = |
  eMedicineSubj  = |
  eMedicineTopic = |
  eMedicine_mult = |
  MeshID        = |
}}
An '''altered level of consciousness''' is any measure of arousal other than normal.  '''Level of consciousness''' ('''LOC''') is a measurement of a person's [[arousal|arousability]] and responsiveness to [[Stimulus (physiology)|stimuli]] from the environment.<ref name="Kandel00">
{{cite book |author=Kandel ER, Jessell, Thomas M.;  Schwartz, James H. |title=Principles of neural science |publisher=McGraw-Hill |location=New York |year=2000 |pages=901 |isbn=0-8385-7701-6 |oclc= |doi= |accessdate=2008-07-03 |url = http://books.google.com/?id=yzEFK7Xc87YC&pg=PA901&dq=%22level+of+consciousness%22}}</ref>  A mildly depressed level of [[consciousness]] or [[alertness]] may be classed as [[lethargy]]; someone in this state can be aroused with little difficulty.<ref name="Kandel00"/>  People who are [[Obtundation|obtunded]] have a more depressed level of consciousness and cannot be fully aroused.<ref name="Kandel00"/><ref name="Porth07"/>  Those who are not able to be aroused from a sleep-like state are said to be [[stupor]]ous.<ref name="Kandel00"/><ref name="Porth07"/>  [[Coma]] is the inability to make any purposeful response.<ref name="Kandel00"/><ref name="Porth07"/>  Scales such as the [[Glasgow coma scale]] have been designed to measure the level of consciousness.


An altered level of consciousness can result from a variety of factors, including alterations in the chemical environment of the brain (e.g. exposure to [[poison]]s or [[intoxicant]]s), insufficient [[oxygen]] or [[blood flow]] in the brain, and excessive [[intracranial pressure|pressure within the skull]].  <!--Level of consciousness may decline abruptly or slowly, or it may increase and decrease intermittently.<ref name="Dohert05"/>--> Prolonged unconsciousness is understood to be a sign of a [[medical emergency]].<ref name="Pollak02"/>  A deficit in the level of consciousness suggests that both of the [[cerebral hemisphere]]s or the [[reticular activating system]] have been injured.<ref name="Porth071">Porth, p. 838</ref>  A decreased level of consciousness correlates to increased morbidity ([[disability]]) and [[mortality rate|mortality]] (death).<ref name="Scheld041">Scheld ''et al.''. p. 530</ref> Thus it is a valuable measure of a patient's medical and neurological status.  In fact, some sources consider level of consciousness to be one of the [[vital sign]]s.<ref name="Pollak02"/><ref name="Forgey99">
{{
cite book |author=Forgey WW |title=Wilderness Medicine, Beyond First Aid, 5th Edition |publisher=Globe Pequot |location=Guilford, Conn |year=1999 |pages  =13 |isbn=0-7627-0490-X |oclc= |doi= |accessdate= 2008-07-04 |url = http://books.google.com/?id=UNwzDUy9AlsC&pg=PA13&dq=%22level+of+consciousness%22
}}
</ref>
==Definition==
Scales and terms to classify the levels of consciousness differ, but in general, reduction in response to stimuli indicates an altered level of consciousness:
{| class="wikitable"
|+ '''Levels of consciousness'''
! Level !! Summary (Kruse)<ref name="Porth07"/> !! Description
|-
! [[Conscious]]
| Normal
| Assessment of LOC involves checking [[Orientation (mental)|orientation]]: people who are able promptly and spontaneously to state their name, location, and the date or time are said to be oriented to self, place, and time, or "oriented X3".<ref name="Kruse86">
{{
cite book |author=Kruse MJ |title=Nursing the Neurological and Neurotrauma Patient |publisher=Rowman & Allanheld |location=Totowa, N.J |year=1986 |pages= 57&ndash;58 |isbn=0-8476-7451-7 |oclc= |doi= |accessdate=
|url= http://books.google.com/?id=3BN3d2Ps8HAC&pg=PA57&dq=%22level+of+consciousness%22#PPA58,M1
}}
</ref>  A normal [[sleep]] stage from which a person is easily awakened is also considered a normal level of consciousness.<ref name="Tindall90"/> "Clouding of consciousness" is a term for a mild alteration of consciousness with alterations in attention and wakefulness.<ref name="Tindall90"/>
|-
! [[Confused]]
|Disoriented; impaired thinking and responses
| People who do not respond quickly with information about their name, location, and the time are considered "obtuse" or "[[confusion|confused]]".<ref name="Kruse86"/>  A confused person may be bewildered, disoriented, and have difficulty following instructions.<ref name="Tindall90"/>  The person may have slow thinking and possible memory time loss.  This could be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs (prescription and nonprescription), and infection. 
|-
![[Delirium|Delirious]]
|Disoriented; restlessness, hallucinations, sometimes delusions
|Some scales have "delirious" below this level, in which a person may be restless or agitated and exhibit a marked deficit in [[attention]].<ref name="Porth07"/> 
|-
![[somnolence|Somnolent]]
| Sleepy
| A ''[[somnolence|somnolent]]''<!--obtunded--> person shows excessive [[drowsiness]] and responds to stimuli only with incoherent mumbles or disorganized movements.<ref name="Kruse86"/>
|-
![[Obtunded]]
|Decreased alertness; slowed psychomotor responses
| In ''[[obtundation]]'', a person has a decreased interest in their surroundings, slowed responses, and sleepiness.<ref name="Tindall90"/> 
|-
![[Stuporous]]
| Sleep-like state (not unconscious); little/no spontaneous activity
|People with an even lower level of consciousness, stupor, only respond by [[Facial expression|grimacing]] or drawing away from painful stimuli.<ref name="Kruse86"/>
|-
![[Coma]]tose
| Cannot be aroused; no response to stimuli
| Comatose people do not even make this response to stimuli, have no [[corneal reflex|corneal]] or [[gag reflex]], and they may have no [[pupillary response]] to light.<ref name="Kruse86"/>
|}
===Glasgow Coma Scale===
{{Main|Glasgow Coma Scale}}
The most commonly used tool for measuring LOC objectively is the [[Glasgow Coma Scale]] (GCS).  It has come into almost universal use for assessing people with [[Acquired brain injury|brain injury]],<ref name="Porth07">{{cite book |author=Porth C |title=Essentials of Pahtophysiology: Concepts of Altered Health States |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2007 |pages=835 |isbn=0-7817-7087-4 |oclc= |doi= |accessdate=2008-07-03 |url= http://books.google.com/?id=57RQC-3OPtUC&pg=PT858&dq=%22level+of+consciousness%22}}</ref> or an altered level of consciousness. Verbal, motor, and eye-opening responses to stimuli are measured, scored, and added into a final score on a scale of 3–15, with a lower score being a more decreased level of consciousness.
===Others===
The [[AVPU]] scale is another means of measuring LOC: people are assessed to determine whether they are '''a'''lert, responsive to '''v'''erbal stimuli, responsive to '''p'''ainful stimuli, or '''u'''nresponsive.<ref name="Pollak02"/><ref name="Forgey99"/>  To determine responsiveness to voice, a caregiver speaks to, or, failing that, yells at the person.<ref name="Pollak02"/>  Responsiveness to pain is determined with a mild painful stimulus such as a pinch; moaning or withdrawal from the stimulus is considered a response to pain.<ref name="Pollak02"/>  The ACDU scale, like AVPU, is easier to use than the GCS and produces similarly accurate results.<ref name="Posner07">{{cite book |author= Posner JB, Saper CB, Schiff ND, Plum F |title=Plum and Posner's Diagnosis of Stupor and Coma |publisher=Oxford University Press, USA |location= |year=2007 |pages=41 |isbn=0-19-532131-6 |oclc= |doi= |accessdate=}}</ref>  Using ACDU, a patient is assessed for '''a'''lertness, '''c'''onfusion, '''d'''rowsiness, and '''u'''nresponsiveness.<ref name="Posner07"/>
The [[Grady Coma Scale]] classes people on a scale of I to V along a scale of confusion, stupor, deep stupor, [[abnormal posturing]], and coma.<ref name="Tindall90"/>
==Differential diagnosis==
A lowered level of consciousness indicate a deficit in brain function.<ref name="Porth071" />  Level of consciousness can be lowered when the brain receives insufficient oxygen (as occurs in [[hypoxia (medical)|hypoxia]]); insufficient blood (as occurs in [[shock (circulatory)|shock]]); or has an alteration in the [[brain chemistry|brain's chemistry]].<ref name="Pollak02">{{cite book |author= Pollak AN, Gupton CL |title=Emergency Care and Transportation of the Sick and Injured |publisher=Jones and Bartlett |location=Boston |year=2002 |pages=140 |isbn=0-7637-1666-9 |oclc= |doi= |accessdate=2008-07-04 |url=http://books.google.com/?id=xAPuKkKA6FEC&pg=PT177&dq=%22level+of+consciousness%22}}</ref>  [[Metabolic disorder]]s such as [[diabetes mellitus]] and [[uremia]] can alter consciousness.<ref name="Dohert05"/>  [[hyponatremia|Hypo-]] or [[hypernatremia]] (decreased and elevated levels of [[sodium]], respectively) as well as [[dehydration]] can also produce an altered LOC.<ref name="Johnson98">
{{cite book |author=Johnson AF, Jacobson BH |title=Medical Speech-language Pathology: A Practitioner's Guide |publisher=Thieme |location=Stuttgart |year=1998 |pages=142 |isbn=0-86577-688-1 |oclc= |doi= |accessdate=2008-07-04 |url= http://books.google.com/?id=Vo5cPaOEG_4C&pg=PA142&vq=level+of+consciousness&dq=%22level+of+consciousness%22}}</ref> A [[pH]] outside of the range the brain can tolerate will also alter LOC.<ref name="Tindall90">{{cite book |author=Tindall SC |editor=Walker HK, Hall WD, Hurst JW |chapter= Level of consciousness |title= Clinical Methods: The History, Physical, and Laboratory Examinations|publisher=Butterworth Publishers |location=|year=1990 |pages= |isbn=|oclc=|doi= |accessdate=2008-07-04 |url= http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&partid=380}}</ref> Exposure to [[drug]]s (e.g. [[alcohol]]) or [[toxin]]s may also lower LOC,<ref name="Pollak02"/> as may a [[core temperature]] that is too high or too low ([[hyperthermia]] or [[hypothermia]]). Increases in [[intracranial pressure]] (the pressure within the skull) can also cause altered LOC.  It can result from [[traumatic brain injury]] such as [[concussion]].<ref name="Dohert05"/>  [[Stroke]] and [[intracranial hemorrhage]] are other causes.<ref name="Dohert05"/> [[Infection]]s of the [[central nervous system]] may also be associated with decreased LOC; for example, an altered LOC is the most common symptom of [[encephalitis]].<ref name="Scheld04">
{{cite book |author= Scheld WM, Whitley RJ, Marra CM |title=Infections of the Central Nervous System |publisher=Lippincott Williams & Wilkins |location=Hagerstown, MD |year=2004 |pages= 219|isbn=0-7817-4327-3 |oclc= |doi= |accessdate=2008-07-04 |url = http://books.google.com/?id=jjvFj6aQeMgC&pg=PA530&dq=%22level+of+consciousness%22#PPA530,M1}}</ref> [[Neoplasm]]s within the [[intracranial cavity]] can also affect consciousness,<ref name="Dohert05"/> as can [[epilepsy]] and [[Postictal state|post-seizure state]]s.<ref name="Tindall90"/> A decreased LOC can also result from a combination of factors.<ref name="Dohert05"/>
A [[concussion]], which is a mild traumatic brain injury (MTBI) may result in decreased LOC.
==Pathophysiology==
Although the neural science behind alertness, wakefulness, and arousal are not fully known, the [[reticular formation]] is known to play a role in these.<ref name="Tindall90"/>  The [[ascending reticular activating system]] is a postulated group of neural connections that receives sensory input and projects to the [[cerebral cortex]] through the [[midbrain]] and [[thalamus]] from the retucular formation.<ref name="Tindall90"/> Since this system is thought to modulate wakefulness and sleep, interference with it, such as injury, illness, or metabolic disturbances, could alter the level of consciousness.<ref name="Tindall90"/>
Normally, stupor and coma are produced by interference with the [[brain stem]], such as can be caused by a [[lesion]] or indirect effects, such as [[brain herniation]].<ref name="Tindall90"/>  Mass lesions in the brain stem normally cause coma due to their effects on the reticular formation.<ref name="Tindall901">
{{
cite book |quote=Mass lesions within the brainstem produce coma by virtue of direct effects on the reticular formation |author=Tindall SC |editor=Walker HK, Hall WD, Hurst JW |chapter= Level of consciousness |title= Clinical Methods: The History, Physical, and Laboratory Examinations
|publisher=Butterworth Publishers |location=|year=1990 |pages= |isbn= |oclc= |doi= |accessdate=2008-07-04 |url= http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&partid=380
}} 
</ref> Mass [[lesion]]s that occur [[supratentorial|above]] the [[tentorium cerebelli]] (pictured) normally do not significantly alter the level of consciousness unless they are very large or affect both [[cerebral hemisphere]]s.<ref name="Tindall90"/>
==Diagnostic approach==
Assessing LOC involves determining an individual's response to external stimuli.<ref name="Dohert05">
{{
cite book |author=von Koch CS, Hoff JT|chapter= Diagnosis and management of depressed states of consciousness |editor=Doherty GM |title=Current Surgical Diagnosis and Treatment |publisher=McGraw-Hill Medical |location= |year=2005 |pages= 863 |isbn=0-07-142315-X |oclc= |doi= |accessdate=2008-07-04 |url= http://books.google.com/?id=c3I-PFkMN2YC&pg=PA863&dq=%22level+of+consciousness%22
}}
</ref>  Speed and accuracy of responses to questions and reactions to stimuli such as touch and pain are noted.<ref name="Dohert05"/>  [[Reflex]]es, such as the [[coughing|cough]] and gag reflexes, are also means of judging LOC.<ref name="Dohert05"/>  Once the level of consciousness is determined, clinicians seek clues for the cause of any alteration.<ref name="Tindall90"/> Usually the first tests in the ER are pulse oximetry to determine if there is hypoxia, serum glucose levels to rule out hypoglycemia. A urine drug screen may be sent. A CT head is very important to obtain to rule out bleed. In case, meningitis is suspected, a lumbar puncture must be performed. A serum TSH is an important test to order. In select groups consider vitamin B12 levels. Checking serum ammonia is not advised.{{Citation needed|date=August 2010}}
==Treatment==
Treatment depends on the degree of decrease in consciousness and its underlying cause.  Initial treatment often involves the administration of [[dextrose]] if the blood sugar is low as well as the administration of [[naloxone]] and [[thiamine]].
==See also==
*[[Altered state of consciousness]]
*[[Disorders of consciousness]]
*[[Level of consciousness (esotericism)]]
==References==
{{Reflist|2}}
{{Cognition, perception, emotional state and behaviour symptoms and signs}}
{{DEFAULTSORT:Altered Level Of Consciousness}}
[[Category:Neuroscience]]
[[Category:Neurological disorders]]
[[Category:Intensive care medicine]]
[[Category:Emergency medicine]]
[[Category:Central nervous system]]

Revision as of 12:44, 22 February 2014

This article is about the medical concept. For the philosophical concept, see Consciousness.

Template:Infobox symptom An altered level of consciousness is any measure of arousal other than normal. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment.[1] A mildly depressed level of consciousness or alertness may be classed as lethargy; someone in this state can be aroused with little difficulty.[1] People who are obtunded have a more depressed level of consciousness and cannot be fully aroused.[1][2] Those who are not able to be aroused from a sleep-like state are said to be stuporous.[1][2] Coma is the inability to make any purposeful response.[1][2] Scales such as the Glasgow coma scale have been designed to measure the level of consciousness.

An altered level of consciousness can result from a variety of factors, including alterations in the chemical environment of the brain (e.g. exposure to poisons or intoxicants), insufficient oxygen or blood flow in the brain, and excessive pressure within the skull. Prolonged unconsciousness is understood to be a sign of a medical emergency.[3] A deficit in the level of consciousness suggests that both of the cerebral hemispheres or the reticular activating system have been injured.[4] A decreased level of consciousness correlates to increased morbidity (disability) and mortality (death).[5] Thus it is a valuable measure of a patient's medical and neurological status. In fact, some sources consider level of consciousness to be one of the vital signs.[3][6]

Definition

Scales and terms to classify the levels of consciousness differ, but in general, reduction in response to stimuli indicates an altered level of consciousness:

Levels of consciousness
Level Summary (Kruse)[2] Description
Conscious Normal Assessment of LOC involves checking orientation: people who are able promptly and spontaneously to state their name, location, and the date or time are said to be oriented to self, place, and time, or "oriented X3".[7] A normal sleep stage from which a person is easily awakened is also considered a normal level of consciousness.[8] "Clouding of consciousness" is a term for a mild alteration of consciousness with alterations in attention and wakefulness.[8]
Confused Disoriented; impaired thinking and responses People who do not respond quickly with information about their name, location, and the time are considered "obtuse" or "confused".[7] A confused person may be bewildered, disoriented, and have difficulty following instructions.[8] The person may have slow thinking and possible memory time loss. This could be caused by sleep deprivation, malnutrition, allergies, environmental pollution, drugs (prescription and nonprescription), and infection.
Delirious Disoriented; restlessness, hallucinations, sometimes delusions Some scales have "delirious" below this level, in which a person may be restless or agitated and exhibit a marked deficit in attention.[2]
Somnolent Sleepy A somnolent person shows excessive drowsiness and responds to stimuli only with incoherent mumbles or disorganized movements.[7]
Obtunded Decreased alertness; slowed psychomotor responses In obtundation, a person has a decreased interest in their surroundings, slowed responses, and sleepiness.[8]
Stuporous Sleep-like state (not unconscious); little/no spontaneous activity People with an even lower level of consciousness, stupor, only respond by grimacing or drawing away from painful stimuli.[7]
Comatose Cannot be aroused; no response to stimuli Comatose people do not even make this response to stimuli, have no corneal or gag reflex, and they may have no pupillary response to light.[7]

Glasgow Coma Scale

Main article: Glasgow Coma Scale

The most commonly used tool for measuring LOC objectively is the Glasgow Coma Scale (GCS). It has come into almost universal use for assessing people with brain injury,[2] or an altered level of consciousness. Verbal, motor, and eye-opening responses to stimuli are measured, scored, and added into a final score on a scale of 3–15, with a lower score being a more decreased level of consciousness.

Others

The AVPU scale is another means of measuring LOC: people are assessed to determine whether they are alert, responsive to verbal stimuli, responsive to painful stimuli, or unresponsive.[3][6] To determine responsiveness to voice, a caregiver speaks to, or, failing that, yells at the person.[3] Responsiveness to pain is determined with a mild painful stimulus such as a pinch; moaning or withdrawal from the stimulus is considered a response to pain.[3] The ACDU scale, like AVPU, is easier to use than the GCS and produces similarly accurate results.[9] Using ACDU, a patient is assessed for alertness, confusion, drowsiness, and unresponsiveness.[9]

The Grady Coma Scale classes people on a scale of I to V along a scale of confusion, stupor, deep stupor, abnormal posturing, and coma.[8]

Differential diagnosis

A lowered level of consciousness indicate a deficit in brain function.[4] Level of consciousness can be lowered when the brain receives insufficient oxygen (as occurs in hypoxia); insufficient blood (as occurs in shock); or has an alteration in the brain's chemistry.[3] Metabolic disorders such as diabetes mellitus and uremia can alter consciousness.[10] Hypo- or hypernatremia (decreased and elevated levels of sodium, respectively) as well as dehydration can also produce an altered LOC.[11] A pH outside of the range the brain can tolerate will also alter LOC.[8] Exposure to drugs (e.g. alcohol) or toxins may also lower LOC,[3] as may a core temperature that is too high or too low (hyperthermia or hypothermia). Increases in intracranial pressure (the pressure within the skull) can also cause altered LOC. It can result from traumatic brain injury such as concussion.[10] Stroke and intracranial hemorrhage are other causes.[10] Infections of the central nervous system may also be associated with decreased LOC; for example, an altered LOC is the most common symptom of encephalitis.[12] Neoplasms within the intracranial cavity can also affect consciousness,[10] as can epilepsy and post-seizure states.[8] A decreased LOC can also result from a combination of factors.[10] A concussion, which is a mild traumatic brain injury (MTBI) may result in decreased LOC.

Pathophysiology

Although the neural science behind alertness, wakefulness, and arousal are not fully known, the reticular formation is known to play a role in these.[8] The ascending reticular activating system is a postulated group of neural connections that receives sensory input and projects to the cerebral cortex through the midbrain and thalamus from the retucular formation.[8] Since this system is thought to modulate wakefulness and sleep, interference with it, such as injury, illness, or metabolic disturbances, could alter the level of consciousness.[8]

Normally, stupor and coma are produced by interference with the brain stem, such as can be caused by a lesion or indirect effects, such as brain herniation.[8] Mass lesions in the brain stem normally cause coma due to their effects on the reticular formation.[13] Mass lesions that occur above the tentorium cerebelli (pictured) normally do not significantly alter the level of consciousness unless they are very large or affect both cerebral hemispheres.[8]

Diagnostic approach

Assessing LOC involves determining an individual's response to external stimuli.[10] Speed and accuracy of responses to questions and reactions to stimuli such as touch and pain are noted.[10] Reflexes, such as the cough and gag reflexes, are also means of judging LOC.[10] Once the level of consciousness is determined, clinicians seek clues for the cause of any alteration.[8] Usually the first tests in the ER are pulse oximetry to determine if there is hypoxia, serum glucose levels to rule out hypoglycemia. A urine drug screen may be sent. A CT head is very important to obtain to rule out bleed. In case, meningitis is suspected, a lumbar puncture must be performed. A serum TSH is an important test to order. In select groups consider vitamin B12 levels. Checking serum ammonia is not advised.[citation needed]

Treatment

Treatment depends on the degree of decrease in consciousness and its underlying cause. Initial treatment often involves the administration of dextrose if the blood sugar is low as well as the administration of naloxone and thiamine.

See also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Kandel ER, Jessell, Thomas M.; Schwartz, James H. (2000). Principles of neural science. New York: McGraw-Hill. p. 901. ISBN 0-8385-7701-6. Retrieved 2008-07-03.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Porth C (2007). Essentials of Pahtophysiology: Concepts of Altered Health States. Hagerstown, MD: Lippincott Williams & Wilkins. p. 835. ISBN 0-7817-7087-4. Retrieved 2008-07-03.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Pollak AN, Gupton CL (2002). Emergency Care and Transportation of the Sick and Injured. Boston: Jones and Bartlett. p. 140. ISBN 0-7637-1666-9. Retrieved 2008-07-04.
  4. ↑ 4.0 4.1 Porth, p. 838
  5. ↑ Scheld et al.. p. 530
  6. ↑ 6.0 6.1 Forgey WW (1999). Wilderness Medicine, Beyond First Aid, 5th Edition. Guilford, Conn: Globe Pequot. p. 13. ISBN 0-7627-0490-X. Retrieved 2008-07-04.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Kruse MJ (1986). Nursing the Neurological and Neurotrauma Patient. Totowa, N.J: Rowman & Allanheld. pp. 57&ndash, 58. ISBN 0-8476-7451-7.
  8. ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 Tindall SC (1990). "Level of consciousness". In Walker HK, Hall WD, Hurst JW. Clinical Methods: The History, Physical, and Laboratory Examinations. Butterworth Publishers. Retrieved 2008-07-04.
  9. ↑ 9.0 9.1 Posner JB, Saper CB, Schiff ND, Plum F (2007). Plum and Posner's Diagnosis of Stupor and Coma. Oxford University Press, USA. p. 41. ISBN 0-19-532131-6.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 von Koch CS, Hoff JT (2005). "Diagnosis and management of depressed states of consciousness". In Doherty GM. Current Surgical Diagnosis and Treatment. McGraw-Hill Medical. p. 863. ISBN 0-07-142315-X. Retrieved 2008-07-04.
  11. ↑ Johnson AF, Jacobson BH (1998). Medical Speech-language Pathology: A Practitioner's Guide. Stuttgart: Thieme. p. 142. ISBN 0-86577-688-1. Retrieved 2008-07-04.
  12. ↑ Scheld WM, Whitley RJ, Marra CM (2004). Infections of the Central Nervous System. Hagerstown, MD: Lippincott Williams & Wilkins. p. 219. ISBN 0-7817-4327-3. Retrieved 2008-07-04.
  13. ↑ Tindall SC (1990). "Level of consciousness". In Walker HK, Hall WD, Hurst JW. Clinical Methods: The History, Physical, and Laboratory Examinations. Butterworth Publishers. Retrieved 2008-07-04. Mass lesions within the brainstem produce coma by virtue of direct effects on the reticular formation

Template:Cognition, perception, emotional state and behaviour symptoms and signs

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