1. ALTERED MENTAL STATUS & COMA Dr makeldin

3. GLASGOW COMA SCALE E : Eye Opening V : Best Verbal Response M : Best Motor Response  total scoring

4. -> Open * Spontaneously 4 * To Verbal 3 * To Pain 2 -> No response 1 EYE OPENING

6. BEST MOTOR RESPONSE -> To Verbal Command * Obey 6 -> To Painful Response * Localizes pain 5 * Flexion withdrawal 4 * Flexion - abnormal 3 * Extension – abnormal 2 * No response 1

7. * Greek word “ Koma ” meaning state of sleep” * Hippocrates, describe this very state of the brain at the lowest end of the spectrum of function. * "coma is a state of unresponsiveness from which an individual has not yet been aroused " . What is COMA

8. Glasgow Coma Scale Score of 8 or less COMA 

9. Advanced Trauma Life Support (ATLS) Level of consciousness-- AVPU A – Alert V – Response to Verbal stimuli P – Response to Pain stimuli U - Unconscious

10. Altered Mental Status ? What are the causes of

11. Emergency Medicine Mnemonic in Altered Mental Status A E I O U T I P S

12. A – Alcohol E – Endocrine / Electrolytes I – Insulin O - Opiate / Oxygen U - Uremia A E I O U ?

13. T I P S ? T – Toxin / trauma / temperature I – Infections P – Psych / Porphyria S – SAH, stroke, shock, space occupying lesion

14. Usually stuporous Blood alcohol > 200mg/dl A - ALCOHOL

15. Blood EtOH level 20-50 Impair fine motor function 50-100 Impair judge & coordination 100-150 Difficult walk & balance 150-200 Lethargy 300 Coma 400 Respiratory depression 500 Potential death

16. E – ENDOCRINE / ELECTROLYTES *Hypothyroidism *Hyperthyroidism *Hyperparathyroidism *Adrenal hypofunction *Diabetes Mellitus *Hyponatremia <120mEq/dl *Hepatic coma *Serum Osmolality <260mOsm/L > 330mOsm/L *Hypercalcemia Ca >19mg/dl *Hyperviscosity > 4cp (1.4-1.8)

17. I – INSULIN Hypoglycemia Adult Plasma < 45mg/dl Child < 40mg/dl Hyperglycemia Glucose > 600 + OSM > 340

18. O – OPIATES / OXYGEN * Meperidine,opiate,codeine, morphine,cocaine etc * CO 2 retension + acidosis Hypoxia

19. U – UREMIA BUN sudden increase > 60mg/100ml

20. T- Toxin /Trauma/Temperature Toxin –- Hypnotic agent, barbiturate Trauma –- multi-factorial Temperature –- *Hyperthermia > 40.5 c *Hypothermia < 32 c

21. I : INFECTIONS CNS & Systemic Infection

22. P : Psych / Porphyria Psychogenic unresponsiveness Porphyrias Anomalies in pigment metabolism Classified into 8 types Symptoms : abdominal pain, diarrhea, constipate,dysuria,ileus,muscle hypotonia, resp insufficiency,sensory neuropathy, seizure, photosensitivity,skin lesion.

23. S SAH: sudden onset severe headache. Space occupying lesion: tumour/blood /abscess/infarction Stroke:hemorhage/infarction/thrombotic Shock: hypovolemic/obstructive, cardiogenic/vasogenic/anaphylatic pharmacologic/neurogenic

24. CLINICAL PRESENTATION ?

26. HEENT Mydriasis - organophosphate Miosis - narcotic, anticholinergic, potine lesion Loss of pupillary reflex or anisocoria - structural lesion Evidence of head trauma - contusion, hematoma, laceration, hemotympanum. Neck - nuchal rigidity, meningitis, SAH

27. NEUROLOGICAL Decorticate Posturing - suggest severe damage above the midbrain. Decerebrate Posturing - suggest damage at the midbrain or diencephalon Asymmetrical Movements - structural lesion Persistent twitching of an extremity - stutus epilepticus

28. Treatment in ER

29. Initial Stabilization A - Airway B – Breathing C – Circulation

30. E D TREATMENT B A N G

31. B : B1 Vitamin A : Anexate N : Naloxone G : Glucose

32. Wernicke’s Encephalopathy Confusion, apathy, drosiness, ataxic, nystagmus, ophthalmoplegia. Cause : chronic alcohol abuse & thiamine deficiency Tx : Thiamine IV Alinamine F, Nutrase

33. Flumazenil ( Anexate ) 0.2 mg IV over 15 sec. Also effective in Hepatic coma

35. Hypoglycemia * Give 20-50g of 50% Glucose. * Then constant IVF glucose till pt can take by mouth.

36. THE END