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Alteration of Consciousness
Reticular activating system  (RAS)
<ul><li>Good Consciousness   =  </li></ul><ul><li>Alertness + Awareness  </li></ul>
<ul><li>Diminished alertness   = </li></ul><ul><li>Widespread abnormalities of cerebral hemispheres or reduced activity of...
Definition of Terms <ul><li>Confusion :  </li></ul><ul><ul><li>impaired attention  and concentration, manifest  disorienta...
Definition of Terms <ul><li>Delirium : confusion and associated agitation, hallucination, convulsion and tremor </li></ul>...
Level of Consciousness(1) <ul><li>Alert  :  normal awake and responsive state </li></ul><ul><li>Drowsiness  :  state of ap...
Level of Consciousness (2) <ul><li>Somnolent :   easily aroused by voice or touch; awakens and follows commands; req uired...
Dementia VS Confusional state <ul><li>Dementia </li></ul><ul><ul><li>Longstanding nature </li></ul></ul><ul><ul><li>Varies...
Causes of confusional state(1) <ul><li>Medical or surgical disease </li></ul><ul><li>Metabolic disorders  </li></ul><ul><u...
Causes of confusional state(2) <ul><li>Infectious illness </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Endoc...
Causes of confusional state(3) <ul><li>Drug intoxication </li></ul><ul><li>Opiates </li></ul><ul><li>Barbiturates </li></u...
Causes of confusional state(4) <ul><li>Diseases of nervous system </li></ul><ul><li>Cerebrovascular disease, tumor, absces...
Approach   <ul><li>History  --- emphasizing the patient’s condition before the onset of confusion </li></ul><ul><li>Clinic...
Aim of care   in confusion patients <ul><li>Control underlying medical illness </li></ul><ul><li>Quiet the patient and pro...
Medical management <ul><li>Haloperidol, quetiapine, risperidone are helpful in calming the agitated and hallucinating pati...
COMA
GLASGOW COMA SCORE <ul><li>Eye opening: </li></ul><ul><li>Nil   1 </li></ul><ul><li>To pain (applied to limbs)   2 </li></...
Glasgow Coma Scale : Eye opening (E)
Glasgow Coma Scale : Motor response (M)
Glasgow Coma Scale : Verbal response (V)
<ul><li>Notes </li></ul><ul><li>scoring from the best response  </li></ul><ul><li>verbal response will not correct in the ...
Approach to the patient <ul><li>History </li></ul><ul><ul><li>Circumstances and rapidity with which neurologic symptoms de...
General physical examination <ul><li>Vital sign </li></ul><ul><ul><li>Temperature </li></ul></ul><ul><ul><ul><li>Fever </l...
Neurologic assessment <ul><li>Observe </li></ul><ul><ul><li>Movement : restless, twitching, multifocal myoclonus, asterixi...
Decorticate posture results from damage to one or both corticospinal tracts
Decerebrate posture results from damage to the upper brain stem
Neurologic assessment <ul><li>Level of arousal and elicited movements </li></ul><ul><li>Brainstem reflexes  </li></ul><ul>...
Pupils in comatose patients <ul><li>DESCRIPTIONS INTERPRETATION </li></ul><ul><li>Small, reactive Metabolic causes </li></...
 
Doll’s eye maneuver (Oculocephalic reflex) Cold caloric test (Oculovestibular reflex)
 
Eye movements   Condition Awake Cerebral dysfunction, brainstem intact Brain stem lesion Doll’s eyes Negative Positive  Ne...
Respiratory patterns
Respiratory pattern(1) <ul><li>Cheyne-Stokes respiration : bilateral cortical or bilateral thalamic lesions, metabolic dis...
Respiratory pattern(2) <ul><li>Least useful sign because : </li></ul><ul><ul><li>Acid-base derangements </li></ul></ul><ul...
Conditions mimic coma   <ul><li>Brain death </li></ul><ul><li>Locked-in syndrome </li></ul><ul><li>Vegetative state  </li>...
Vegetative state <ul><li>An  awake but unresponsive state </li></ul><ul><li>Extensive damage in both cerebral hemisphere <...
Locked-in state <ul><li>Awake  patient has  no means of producing speech or volitional limb, face and pharyngeal movements...
COMA LOCALIZING SIGN NO LOCALIZING SIGN SUPRATENTORIAL  INFRATENTORIAL NO STIFF NECK STIFF NECK - CVD - TUMOUR - ABSCESS S...
Blood test <ul><li>CBC </li></ul><ul><li>FBS </li></ul><ul><li>BUN, Creatinine </li></ul><ul><li>Electrolyte, calcium </li...
Other tests <ul><li>EKG </li></ul><ul><li>CT or MRI brain </li></ul><ul><li>CSF exam </li></ul><ul><li>EEG </li></ul>
Prognosis of coma <ul><li>Recovery from coma depends primarily on the causes, rather than on the depth of coma  </li></ul>...
Brain Herniation <ul><li>Central transtentorial herniation </li></ul>
<ul><li>Uncal transtentorial herniation </li></ul>Brain Herniation
Management of Transtentorial herniation <ul><li>Intubation and   hyperventilation (P CO 2  25-30 mmHg) </li></ul><ul><li>M...
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Alteration Of Consciousness

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Alteration Of Consciousness

  1. 1. Alteration of Consciousness
  2. 2. Reticular activating system (RAS)
  3. 3. <ul><li>Good Consciousness = </li></ul><ul><li>Alertness + Awareness </li></ul>
  4. 4. <ul><li>Diminished alertness = </li></ul><ul><li>Widespread abnormalities of cerebral hemispheres or reduced activity of reticular activating system (RAS) </li></ul>
  5. 5. Definition of Terms <ul><li>Confusion : </li></ul><ul><ul><li>impaired attention and concentration, manifest disorientation in time, place and person , impersistent thinking, speech and performance, reduced comprehension and capacity to reason </li></ul></ul><ul><ul><li>Fluctuate in severity, typically worse at night ‘sundowning’ </li></ul></ul><ul><ul><li>Perceptual disturbances and misinterpret voices, common objects and actions of other persons </li></ul></ul><ul><li>Confusion is also found in dementia (progressive failure of language, memory, and other intellectual functions) </li></ul>
  6. 6. Definition of Terms <ul><li>Delirium : confusion and associated agitation, hallucination, convulsion and tremor </li></ul><ul><li>Amnesia : a loss of past memories and to an ability to form new ones, despite alert and normal attentiveness </li></ul>
  7. 7. Level of Consciousness(1) <ul><li>Alert  : normal awake and responsive state </li></ul><ul><li>Drowsiness : state of apparent sleep, briefly arousal with oral command </li></ul><ul><li>Lethargic  : resembles sleepiness, but not becoming fully alert, slow verbal response and inattentive. Unable to adequately perform simple concentration task (such as counting 20 to 1) </li></ul>
  8. 8. Level of Consciousness (2) <ul><li>Somnolent :  easily aroused by voice or touch; awakens and follows commands; req uired stim ulation to maintain arousal </li></ul><ul><li>Obtunded/Stuporous  : arousable only with repeated and painful stimulation; verbal output is unintelligible or nil; some purposeful movement to noxious stimulation </li></ul><ul><li>Comatose : no arousal despite vigorous stim ulation , no purposeful movement- only posturing, brainstem reflexes often absent </li></ul>
  9. 9. Dementia VS Confusional state <ul><li>Dementia </li></ul><ul><ul><li>Longstanding nature </li></ul></ul><ul><ul><li>Varies little from time to time </li></ul></ul><ul><ul><li>Memory problem </li></ul></ul><ul><li>Confusional state </li></ul><ul><ul><li>Acute </li></ul></ul><ul><ul><li>Fluctuate </li></ul></ul><ul><ul><li>Clouding of consciousness </li></ul></ul>
  10. 10. Causes of confusional state(1) <ul><li>Medical or surgical disease </li></ul><ul><li>Metabolic disorders </li></ul><ul><ul><li>Hepatic </li></ul></ul><ul><ul><li>Uremic </li></ul></ul><ul><ul><li>Hypo and hypernatremia </li></ul></ul><ul><ul><li>Hypercalcemia </li></ul></ul><ul><ul><li>Hypo and hyperglycemia </li></ul></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Hypercapnia </li></ul></ul>
  11. 11. Causes of confusional state(2) <ul><li>Infectious illness </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Endocarditis </li></ul></ul><ul><ul><li>Urinary tract infection </li></ul></ul><ul><ul><li>Peritonitis </li></ul></ul><ul><li>Congestive heart failure </li></ul><ul><li>Postoperative and posttraumatic states </li></ul>
  12. 12. Causes of confusional state(3) <ul><li>Drug intoxication </li></ul><ul><li>Opiates </li></ul><ul><li>Barbiturates </li></ul><ul><li>Other sedatives </li></ul>
  13. 13. Causes of confusional state(4) <ul><li>Diseases of nervous system </li></ul><ul><li>Cerebrovascular disease, tumor, abscess </li></ul><ul><li>Subdural hematoma </li></ul><ul><li>Meningitis </li></ul><ul><li>Encephalitis </li></ul><ul><li>Cerebral vasculitis </li></ul><ul><li>Hypertensive encephalopathy </li></ul>
  14. 14. Approach <ul><li>History --- emphasizing the patient’s condition before the onset of confusion </li></ul><ul><li>Clinical examination --- focus on </li></ul><ul><ul><li>signs of diminished attentiveness, disorientation, and drowsiness and </li></ul></ul><ul><ul><li>the presence of localizing neurological signs </li></ul></ul>
  15. 15. Aim of care in confusion patients <ul><li>Control underlying medical illness </li></ul><ul><li>Quiet the patient and protect him from injury </li></ul><ul><li>Discontinue drugs that could possibly be responsible for the acute confusional state : sedating, antianxiety, narcotic, anticholinergic, antispasticity, corticosteroid, L-dopa, metoclopramide, cimetidine, antidepressant, antiarrhythmic,anticonvulsant, antibiotics. </li></ul>
  16. 16. Medical management <ul><li>Haloperidol, quetiapine, risperidone are helpful in calming the agitated and hallucinating patient, but should be used in the lowest effective doses </li></ul><ul><li>In alcohol or sedative withdrawal—chlordiazepoxide is the drug of choice. Chloral hydrate, lorazepam, and diazepam are equally effective </li></ul>
  17. 17. COMA
  18. 18. GLASGOW COMA SCORE <ul><li>Eye opening: </li></ul><ul><li>Nil 1 </li></ul><ul><li>To pain (applied to limbs) 2 </li></ul><ul><li>To voice (including command) 3 </li></ul><ul><li>Spontaneous (with blinking ) 4 </li></ul><ul><li>Motor response: </li></ul><ul><li>Nil 1 </li></ul><ul><li>Arm extension to pain (nail bed pressure) 2 </li></ul><ul><li>Arm flexion to pain (nail bed pressure) 3 </li></ul><ul><li>Arm withdrawal from pain (nail bed pressure)4 </li></ul><ul><li>Hand localizes pain(supraorbital or chest pressure)5 </li></ul><ul><li>Obeys commands 6 </li></ul><ul><li>Verbalize response: </li></ul><ul><li>NIL 1 </li></ul><ul><li>Groans (no re-cognizable words) 2 </li></ul><ul><li>Inappropriate words (including expletives) 3 </li></ul><ul><li>Confused speech 4 Orientated 5 </li></ul>
  19. 19. Glasgow Coma Scale : Eye opening (E)
  20. 20. Glasgow Coma Scale : Motor response (M)
  21. 21. Glasgow Coma Scale : Verbal response (V)
  22. 22. <ul><li>Notes </li></ul><ul><li>scoring from the best response </li></ul><ul><li>verbal response will not correct in the condition of aphasia, intubation and facial injury </li></ul><ul><li>sensory loss may interfere painful stimulation </li></ul><ul><li>eye opening may be interfered by orbital swelling and 3 rd CN palsy </li></ul><ul><li>arm movements may be impaired from local trauma or cervical cord lesion </li></ul>GLASGOW COMA SCORE
  23. 23. Approach to the patient <ul><li>History </li></ul><ul><ul><li>Circumstances and rapidity with which neurologic symptoms developed </li></ul></ul><ul><ul><li>Immediately preceding medical and neurologic symptoms </li></ul></ul><ul><ul><li>Use of medications, illicit drugs, or alcohol </li></ul></ul><ul><ul><li>Chronic liver, kidney, lung, heart, or other medical disease </li></ul></ul>
  24. 24. General physical examination <ul><li>Vital sign </li></ul><ul><ul><li>Temperature </li></ul></ul><ul><ul><ul><li>Fever </li></ul></ul></ul><ul><ul><ul><li>Hypothermia -- <31 °C causes coma </li></ul></ul></ul><ul><ul><li>Pulse </li></ul></ul><ul><ul><li>Respiratory rate and pattern </li></ul></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><li>Funduscopic examination </li></ul><ul><li>Cutaneous lesion </li></ul>
  25. 25. Neurologic assessment <ul><li>Observe </li></ul><ul><ul><li>Movement : restless, twitching, multifocal myoclonus, asterixis </li></ul></ul><ul><ul><li>Decorticate rigidity </li></ul></ul><ul><ul><li>Suggest severe bilateral damage rostral to midbrain </li></ul></ul><ul><ul><li>Decerebrate rigidity </li></ul></ul><ul><ul><li>Indicate damage to motor tracts in the midbrain or caudal diencephalon </li></ul></ul>
  26. 26. Decorticate posture results from damage to one or both corticospinal tracts
  27. 27. Decerebrate posture results from damage to the upper brain stem
  28. 28. Neurologic assessment <ul><li>Level of arousal and elicited movements </li></ul><ul><li>Brainstem reflexes </li></ul><ul><ul><li>pupils </li></ul></ul><ul><ul><li>Ocular movements </li></ul></ul><ul><ul><li>respiration </li></ul></ul>
  29. 29. Pupils in comatose patients <ul><li>DESCRIPTIONS INTERPRETATION </li></ul><ul><li>Small, reactive Metabolic causes </li></ul><ul><li>Diencephalic lesion </li></ul><ul><li>Midposition, fixed Mid brain lesion </li></ul><ul><li>large, fixed Extensive brain stem lesion </li></ul><ul><li>A noxia </li></ul><ul><li>S edative overdose </li></ul><ul><li>A nticholinergic poisoning or </li></ul><ul><li>mydriatic eyedrops </li></ul><ul><li>Pin point Pontine lesion </li></ul><ul><li>Opiates </li></ul><ul><li>Unilateral fixed dilated T hird nerve palsy </li></ul>
  30. 31. Doll’s eye maneuver (Oculocephalic reflex) Cold caloric test (Oculovestibular reflex)
  31. 33. Eye movements Condition Awake Cerebral dysfunction, brainstem intact Brain stem lesion Doll’s eyes Negative Positive Negative Condition Awake Cerebral dysfunction, brainstem intact Brain stem lesion Cold calorics Nystagmus, N/V, pain Slow deviation toward water Negative
  32. 34. Respiratory patterns
  33. 35. Respiratory pattern(1) <ul><li>Cheyne-Stokes respiration : bilateral cortical or bilateral thalamic lesions, metabolic disturbances, incipient transtentorial herniation </li></ul><ul><li>Hyperventilation : midbrain or pons lesions </li></ul><ul><li>Apneusis : lateral tegmentum of lower half of pons </li></ul><ul><li>Cluster : lower pontine or high medullary lesions </li></ul><ul><li>Ataxic : dorsomedial medulla lesion </li></ul>
  34. 36. Respiratory pattern(2) <ul><li>Least useful sign because : </li></ul><ul><ul><li>Acid-base derangements </li></ul></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Cardiac influences </li></ul></ul>
  35. 37. Conditions mimic coma <ul><li>Brain death </li></ul><ul><li>Locked-in syndrome </li></ul><ul><li>Vegetative state </li></ul><ul><li>Frontal lobe disease </li></ul><ul><li>Non-convulsive status epilepticus </li></ul><ul><li>Psychiatric disorder (catatonia, depression) </li></ul>
  36. 38. Vegetative state <ul><li>An awake but unresponsive state </li></ul><ul><li>Extensive damage in both cerebral hemisphere </li></ul><ul><li>Retained respiratory and autonomic functions </li></ul><ul><li>Cardiac arrest and head injury are the most common causes. </li></ul>
  37. 39. Locked-in state <ul><li>Awake patient has no means of producing speech or volitional limb, face and pharyngeal movements </li></ul><ul><li>Vertical eye movement and lid elevation remain unimpaired </li></ul><ul><li>Infarction or hemorrhage of the ventral pons </li></ul>
  38. 40. COMA LOCALIZING SIGN NO LOCALIZING SIGN SUPRATENTORIAL INFRATENTORIAL NO STIFF NECK STIFF NECK - CVD - TUMOUR - ABSCESS STRU C TURAL DAMAGE FUNCTIONAL NEURONAL DEPRESSION - HYPOXIA - CARDIAC ARREST - ENCEPHALITIS - HEPATIC - URAEMIC - POST ICTAL STATE - FLUID ELECTROLYTE IMBALANCE - DRUGS - SAH - MENINGITIS
  39. 41. Blood test <ul><li>CBC </li></ul><ul><li>FBS </li></ul><ul><li>BUN, Creatinine </li></ul><ul><li>Electrolyte, calcium </li></ul><ul><li>LFT </li></ul><ul><li>Drug screen, toxicology screen </li></ul>
  40. 42. Other tests <ul><li>EKG </li></ul><ul><li>CT or MRI brain </li></ul><ul><li>CSF exam </li></ul><ul><li>EEG </li></ul>
  41. 43. Prognosis of coma <ul><li>Recovery from coma depends primarily on the causes, rather than on the depth of coma </li></ul><ul><li>Intoxication and metabolic causes carry the best prognosis </li></ul><ul><li>Coma from traumatic head injury far better than those with coma from other structural causes </li></ul><ul><li>Coma from global hypoxic-ischemic carries least favorable prognosis </li></ul><ul><li>At 3 rd day, no papillary light reflex or GCS < 5 is associated with poor prognosis </li></ul>
  42. 44. Brain Herniation <ul><li>Central transtentorial herniation </li></ul>
  43. 45. <ul><li>Uncal transtentorial herniation </li></ul>Brain Herniation
  44. 46. Management of Transtentorial herniation <ul><li>Intubation and hyperventilation (P CO 2 25-30 mmHg) </li></ul><ul><li>Mannitol (0.5-1 gm/kg body weight or 20 % mannitol 200 cc. infusion 10-20 minutes repeat every 4 hours if necessary </li></ul><ul><li>Furosemide 20-40 mg IV </li></ul><ul><li>Dexamethasone 4-10 mg IV q 6 hours decrease perilesional vasogenic cerebral edema. Active at 24-48 hours. </li></ul><ul><li>Consult surgery </li></ul>

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