Degrees of impaired consciousness
According to the classification, several stages of decreased wakefulness are distinguished. The patient's ability to communicate and respond adequately to stimuli is assessed primarily.
1. Mild degree (Stupor)
When stupor develops, the patient is completely disoriented in time and space. Externally, the patient appears extremely lethargic and drowsy. Verbal contact is difficult: answers to questions are confused and delayed. However, basic communication ability is partially preserved.
- Contact: the patient is able to follow the physician's simplest commands (for example, can open eyes or stick out the tongue upon request).
- Neurological status: basic reflex activity is preserved. Examination of the pupils reveals a brisk reaction to light stimulus.
2. Moderate degree (Sopor)
Sopor represents a deeper depression of central nervous system functions. Visually, the condition resembles a deep pathological sleep. Unlike the mild degree, it is not possible to wake such a patient or obtain a meaningful response from them.
- Contact: execution of any, even the simplest commands, is completely absent.
- Response to pain: this is a key criterion. Pain sensitivity is preserved. In response to intense stimulation (needle prick or pinch), the patient makes involuntary defensive movements—attempts to push the physician's hand away or turns the head.
- Neurological status: the pupils remain of normal diameter or may be slightly dilated, while the reaction to light remains well-preserved.
Associated clinical presentation
Impaired consciousness rarely occurs in isolation. In surgical and traumatological practice, when examining such a patient, the physician must pay attention to a number of critical signs indicating systemic disorders:
- Skin color: pronounced cyanosis of the skin and visible mucous membranes typically appears.
- Hemodynamics: development of tachycardia.
- Assessment of respiration: it is necessary to record the presence of spontaneous breathing, and assess its rate, depth, and rhythm regularity.
- Pathological patterns: participation of accessory muscles (neck and chest muscles) in the act of breathing, as well as the presence of paradoxical excursions of the chest wall.
Main causes (etiology) of disorders
Depression of consciousness accompanied by the symptoms described above most commonly occurs against the background of severe trauma, acute hypoxia, or massive blood loss. Leading etiological factors include:
- High-intensity pain syndrome: occurs with chest compression or severe contusion, rib fractures, and diaphragmatic rupture.
- CNS lesions: direct brain injury accompanied by damage to the respiratory center, which can lead to complete cessation of breathing.
- Airway obstruction: mechanical blockage of the lumen by blood, mucus, or vomitus. In an unconscious state (sopor, coma), posterior displacement of the tongue is a frequent cause of obstruction.
- Reduction of the respiratory surface of the lungs: occurs due to compression of lung tissue during the development of hemothorax or pneumothorax.
- Disruption of biomechanics: characteristic of double multiple rib fractures, when the chest loses its structural rigidity.
- Massive hemorrhage: leads to severe tissue hypoperfusion and the formation of "shock lung" syndrome.
Briefly: answers to topical questions
What degrees of impaired consciousness are distinguished in clinical practice?
In clinical practice, the following stages of quantitative decrease (depression) of consciousness are distinguished:
- Stupor — the ability to answer questions is preserved, but the answers are insufficiently meaningful.
- Obtundation — the threshold of perception of external stimuli is elevated, mental processes are slowed, and orientation is incomplete or absent.
- Sopor (sopor) — a deep stage of obtundation characterized by the absence of response to verbal communication, while the response to painful stimuli is preserved.
- Coma — deep CNS depression with complete loss of consciousness and responses to any external stimuli.
What is the Glasgow Coma Scale and by what criteria does it assess the level of consciousness?
The Glasgow Coma Scale is a tool for determining the severity of coma and assessing the degree of consciousness impairment. The assessment of the level of consciousness is made up of the sum of points across three parameters:
- Eye opening — the patient's response is assessed.
- Motor response — evaluated on a scale from 1 to 6 points.
- Verbal response — verbal contact is evaluated.
The total score ranges from 3 points (brain death or deep coma) to 15 points (clear consciousness).
What stages of coma are distinguished in surgery and intensive care?
The presented materials describe the following stages and degrees of coma:
- Moderate coma — corresponds to 6–7 points on the Glasgow Coma Scale.
- Deep coma (Stage II coma) — total CNS depression with complete absence of consciousness, response to pain, and pupillary reflexes.
- Terminal coma (beyond coma) — corresponds to 4–5 points. Characterized by diffuse muscle hypotonia, areflexia, and severe autonomic dysfunction.
Stupor — Listens (follows commands, but is lethargic), Sopor — Sleeps (pathological sleep, responds only to pain).
Class and exam questions
How to differentiate stupor and sopor during the initial examination?
The main difference lies in the response to commands. In a state of stupor, the patient can open eyes or show the tongue at the doctor's request, whereas in sopor, execution of commands is impossible — the patient is in a state of pathological sleep.
Is the pupillary reflex preserved in sopor?
Yes, in moderate impairment of consciousness, pupils can be normal or slightly dilated, but the reaction to light remains good.
How does a patient in sopor respond to painful stimuli?
The response to pain is preserved: in response to a pinch or prick, the patient makes involuntary defensive movements, for example, withdraws the hand or turns the head.
Why is there a risk of airway obstruction in an unconscious state?
During depression of consciousness, muscle relaxation occurs, which often leads to posterior displacement of the tongue. In addition, the airways can be blocked by accumulated mucus, blood, or vomitus.
What else to study on this topic
- Pathophysiology of "shock lung" in massive hemorrhage
- Mechanism of paradoxical chest wall excursions in double rib fractures
- Differential diagnosis of hemothorax and pneumothorax
- Emergency care for posterior tongue displacement
- Assessment of coma depth and the Glasgow scale
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