Intubated patient: lift sedation (e.g., propofol) and place the patient on a pressure support mode (e.g., 10 cm pressure support with 5 cm PEEP).Nonintubated patient: simple observation.No motor response (GCS M1): Lesions below the pons may cause loss of all motor responsiveness (other than spinal reflexes such as triple flexion of the lower limbs).However, occasionally severe toxic/metabolic etiologies may also cause decerebrate posturing (e.g., hepatic encephalopathy) normal pupillary size and response may support a toxic/metabolic etiology. This may be associated with downward herniation, or compression of the brainstem by posterior fossa lesions. Extensor posturing (decerebrate GCS M2) is loosely associated with damage at the level of the midbrain.Flexor posturing (decorticate GCS M3) is loosely associated with damage at the level of the thalamus.The patient is able to move somewhat, but not in a meaningful way to evade the source of pain. This may include crude movements, or flexion of the arm towards the source of pain. Withdraws to pain (GCS M4): The patient moves their arm in response to pain.(2) Arm crosses midline, in efforts to alleviate a painful stimulus on the contralateral side.(1) Stimulation of the supraorbital ridge or temporomandibular joint, causing the patient to bring their hand to their head.Localizing to pain (GCS M5): Patient brings their hand towards the source of pain in a meaningful attempt to alleviate it.Motor responses to pain (listed below).Presence of any asymmetry (e.g., an asymmetric grimace or motor response implies the presence of a focal lesion).Triple flexion is also suggested if the patient responds exactly the same way, regardless of where their foot is stimulated (e.g., dorsum vs. Extremity flexion without grimacing in the lower extremity may be seen in the presence of brain death, due to a spinal reflex known as triple flexion.Grimacing without withdrawal may suggest an intact sensory response, with motor paralysis.⚠️ Sternal rub is contraindicated in patients status post recent surgical sternotomy.This may be useful for patients who are unresponsive to less aversive stimuli. A sternal rub may be less precise, but it provides very potent stimulation.Supraorbital pressure may be helpful, as this facilitates differentiation between localization versus withdrawal.For stuporous/comatose patients, apply painful stimuli to four extremities and bilateral face (e.g., supraorbital ridge, temporomandibular joints, or a Q-tip within the nose).For awake patients, ask them to move their extremities.
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