Question: A 29 year old healthy male suffered carbon monoxide poisoning. He attempted suicide in a closed garage while the cars engine was running. The estimated time he was exposed to the gas was about 2 hours. This was on the 19th December 2011. He was found unconcious and foaming at the mouth. He has been in ICU since then. He has been unconscious for eight days now. They removed him off a ventilator after three days and he is breathing on his own and is being given wall oxygen. He responds to pain and sometimes normal touch. He has been restless and has been moving his limbs to rest in different positions. When stimulated by pain, he pulls his face and withdraws from the painful stimulation. His left arm withdraws from pain and his right arm pulls inward. His body goes into a tremor for short periods than stops. When the bottom of his feet is tickled he pulls his leg upward. His eyes are now fully open, even when not stimulated and closes after some time, his pupils make slight movement from left to right but he does not blink or respond to any commands. What does this mean?How severe is the brain damage with the above symptoms and what are the chances of recovery and in such cases when do these patients wake up?Can you determine the extent of brain damage and what the effects will be when he comes out of unconsciousness? Is there a chance that the brain damage might not be severe at all. Is it a good sign that he has eye movement and pain response after only three days of poisoning? Does that mean he is recovering and will wake up soon?

 EYE RESPONSE

1. No eye opening
2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.)
3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.)
4. Eyes opening spontaneously

Verbal response

1. No verbal response
2. Incomprehensible sounds. (Moaning but no words.)
3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange)
4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.)
5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.)

Motor response

1. No motor response
2. Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response)
3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands. (The patient does simple things as asked.)

His score:
Eye Response - 4
Verbal Response - 1
Motor Response - 4

Hi Dr XXXXXXX thank you for your response. An MRI indicated no brain damage, however he still remains unconscious for eight days. What can be the reason that he has not woken up as yet? Do all his symptoms indicate recovery and in such cases how long do patients like this take to wake up from unconsciousness?