Confusion, Stupor, and Coma

Confusion, Stupor, and Coma is a topic covered in the Harrison's Manual of Medicine.

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Approach to the patient

Disorders of consciousness are common; these always signify a disorder of the nervous system. Assessment should determine the level of consciousness (drowsy, stuporous, comatose) and/or content of consciousness (confusion, perseveration, hallucinations). Confusion is a lack of clarity in thinking with inattentiveness; delirium is used to describe an acute confusional state; stupor, a state in which vigorous stimuli are needed to elicit a response; coma, a condition of unresponsiveness. Pts in such states are usually seriously ill, and etiologic factors must be assessed (Tables 16-1 and 16-2).

 Prescription medications: especially those with anticholinergic properties, narcotics, and benzodiazepines
 Drugs of abuse: alcohol intoxication and alcohol withdrawal, opiates, ecstasy, LSD, GHB, PCP, ketamine, cocaine, “bath salts,” marijuana and its synthetic forms
 Poisons: inhalants, carbon monoxide, ethylene glycol, pesticides
Metabolic conditions
 Electrolyte disturbances: hypoglycemia, hyperglycemia, hyponatremia, hypernatremia, hypercalcemia, hypocalcemia, hypomagnesemia
 Hypothermia and hyperthermia
 Pulmonary failure: hypoxemia and hypercarbia
 Liver failure/hepatic encephalopathy
 Renal failure/uremia
 Cardiac failure
 Vitamin deficiencies: B12, thiamine, folate, niacin
 Dehydration and malnutrition
 Systemic infections: urinary tract infections, pneumonia, skin and soft tissue infections, sepsis
 CNS infections: meningitis, encephalitis, brain abscess
Endocrine conditions
 Hyperthyroidism, hypothyroidism
 Adrenal insufficiency
Cerebrovascular disorders
 Global hypoperfusion states
 Hypertensive encephalopathy
 Focal ischemic strokes and hemorrhages (rare): especially nondominant parietal and thalamic lesions
Autoimmune disorders
 CNS vasculitis
 Cerebral lupus
 Neurologic paraneoplastic syndromes
Seizure-related disorders
 Nonconvulsive status epilepticus
 Intermittent seizures with prolonged postictal states
Neoplastic disorders
 Diffuse metastases to the brain
 Gliomatosis cerebri
 Carcinomatous meningitis
 CNS lymphoma
Terminal end-of-life delirium
Abbreviations: GHB, γ-hydroxybutyrate; LSD, lysergic acid diethylamide; PCP, phencyclidine.

Initial evaluation

 History with special attention to medications (including over-the-counter and herbals)

 General physical examination and neurologic examination

 Complete blood count

 Electrolyte panel including calcium, magnesium, phosphorus

 Liver function tests, including albumin

 Renal function tests

First-tier further evaluation guided by initial evaluation

 Systemic infection screen

  Urinalysis and culture

  Chest radiograph

  Blood cultures


 Arterial blood gas

 Serum and/or urine toxicology screen (perform earlier in young persons)

 Brain imaging with MRI with diffusion and gadolinium (preferred) or CT

 Suspected CNS infection: lumbar puncture after brain imaging

 Suspected seizure-related etiology: EEG (if high suspicion, should be performed immediately)

Second-tier further evaluation

 Vitamin levels: B12, folate, thiamine

 Endocrinologic laboratories: TSH and free T4; cortisol

 Serum ammonia

 Sedimentation rate

 Autoimmune serologies: ANA, complement levels; p-ANCA, c-ANCA. consider paraneoplastic serologies

 Infectious serologies: RPR; fungal and viral serologies if high suspicion; HIV antibody

 Lumbar puncture (if not already performed)

 Brain MRI with and without gadolinium (if not already performed)

Abbreviations: c-ANCA, cytoplasmic antineutrophil cytoplasmic antibody; CNS, central nervous system; p-ANCA, perinuclear antineutrophil cytoplasmic antibody; RPR, rapid plasmin reagin; TSH, thyroid-stimulating hormone.

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