Why does paralysed person show no response to stimuli?
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Answer:
Assessment of the Awake but Unresponsive Patient
Jeff C. Huffman, M.D. and Theodore A. Stern, M.D.
Additional article information
Abstract
The Psychiatric Consultation Service at Massachusetts General Hospital (MGH) sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their thrice-weekly rounds, Dr. Huffman and Dr. Stern discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.
The sight of an apparently awake but unresponsive patient challenges the clinical skills of all practitioners. Diagnostic and therapeutic strategies may not be readily obvious, and the clinician may be unsure of what to do next. Debate frequently arises regarding the medical, psychiatric, or neurologic etiologies of the unresponsiveness, and it may be difficult to determine appropriate interventions.
Have you ever wondered how to distinguish among the many possible causes of unresponsiveness? Are you uncertain about which diagnostic tools and treatments to use in the care of these perplexing patients? How can you determine if a patient's lack of interaction is due to a medical cause or a psychiatric illness? The following case and ensuing discussion highlight diagnostic considerations and strategies for care of the unresponsive patient.
Case Presentation
Emergency medical technicians (EMTs) found Ms. H, a 55-year-old woman with a history of hypertension, coronary artery disease, and depression, lying motionless on the couch in her apartment. Her neighbors had called the police because she had neither left her house nor answered her door for 6 days. Upon arriving at her home, EMTs discovered that Ms. H was minimally responsive; her vital signs were normal except for a pulse of 100 beats/min. She withdrew to noxious stimuli but did not otherwise show purposeful movement. After her arrival in the emergency room, further examination revealed that her pupils were equal and reactive to light; examination of the heart, lungs, abdomen, and extremities was unremarkable. Serum and urine toxicologic screening test results were normal. The chest x-ray, electrocardiogram (ECG), complete blood count, serum chemistries, urinalysis, and liver function test results were also unremarkable. A computerized tomographic scan of the head revealed abnormalities in the left frontal lobe consistent with cerebral infarction.
Ms. H was admitted to the neurology service for evaluation and work-up of her mental status change and possible cerebrovascular accident. Despite having essentially normal vital signs and a “nonfocal” neurologic examination (she spontaneously moved all 4 extremities on occasion), she remained unresponsive to voice, light touch, and other stimuli. However, at most times, she seemed awake and possibly aware of her surroundings. Interview of the family revealed that Ms. H had appeared depressed the preceding 2 weeks and that she had never had similar episodes of depression or unresponsiveness. Psychiatry was consulted to evaluate “psychogenic causes of unresponsiveness.”
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