![]() Accordingly, there is a critical need to improve the clinical evaluation of consciousness using non behavioral based, physiologically based measures. Indeed, such behaviours are often decoupled from consciousness as a direct result of the brain injury. While other more sophisticated measures exist (e.g., JFK Coma Recovery Scale - Revised), many of these tests rely on the observation of behaviours (e.g., motor and/or communicative responses) that may be impaired in brain injured people. Regrettably, the time-honored structural imaging techniques (computed tomography, magnetic resonance imaging) and crude behavioural assessments (Glasgow Coma Scale) that are routinely used to assess altered consciousness are inadequate. More recently, the dramatic increase in survivable brain injuries occurring during military conflicts is also emphasizing the need for improved tools with which to assess consciousness. These cases highlighted the need to assess an individual's level of consciousness beyond simply observing their behavioural status. ![]() This public fascination with consciousness was well exemplified by the media attention focused upon the medical/legal/ethical problems of the Terri Schiavo and Terry Wallis cases. The dilemma of assessing consciousness is also of public interest - and the public is looking towards medical science for insights. ![]() Given the myriad of common disorders that alter consciousness, the need for more sophisticated clinical assessment methods is an important and pragmatic issue. While philosophy has focused on the mind-body problem, and psychology has focused on knowledge of experience, remarkably little attention has been paid to the practical problems that arise from our inability to rigorously evaluate consciousness in the clinical setting. Based on the evidence to-date, electroencephalographic and neuroimaging based assessments of consciousness provide valuable information for evaluation of residual function, formation of differential diagnoses, and estimation of prognosis.Ĭonsciousness is a poorly-defined concept, the meaning of which is more a matter of debate than an issue of certainty. This paper reviews recent advances in physiologically based measures that enable better evaluation of consciousness states (coma, vegetative state, minimally conscious state, and locked in syndrome). The solution must involve objective, physiologically based measures that do not rely on behaviour. While these methods have some utility, estimates of misdiagnosis are worrisome (as high as 43%) - clearly this is a major clinical problem. Current methods for evaluating altered levels of consciousness are highly reliant on either behavioural measures or anatomical imaging. However, times are changing and the need to clinically assess consciousness is increasingly becoming a real-world, practical challenge. Minimal motor weakness of the lower extremities was present.In clinical neurology, a comprehensive understanding of consciousness has been regarded as an abstract concept - best left to philosophers. The patient's vital signs were monitored for approximately 15 min, during which time her blood pressure ranged from 145/85 to 105/55 mmHg. A continuous epidural infusion was initiated with a solution containing 0.06% bupivacaine and fentanyl, 2 μg/ml, at 15 ml/h. The test dose was considered negative on the basis of no change in heart rate, or development of dense spinal blockade. A single open end-hole epidural catheter was threaded approximately 4-cm into the epidural space and an epidural test dose (1.5% lidocaine with epinephrine 1:200,000 ) was administered. The intrathecal injection consisted of 25 μg fentanyl (fentanyl Elkins-Sinn, Inc., Cherry Hill, NJ, USA 50 μg/ml, 0.5-ml) in combination with 2.5 mg bupivacaine (Sensorcaine-MPF Astra USA, Inc., Westborough, MA, USA 0.5%, 0.5-ml). The patient was placed in the sitting position, and combined spinal-epidural analgesia was initiated at the 元–L4 interspace via a needle through needle technique, using a 17-gauge epidural needle and a 27-gauge Whitacre spinal needle (Becton Dickinson, Franklin Lakes, NJ).
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