Altered Consciousness

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Altered Consciousness

  1. 1. <ul><li>بسم الله الرحمن الرحيم </li></ul>
  2. 2. Altered consciousness and coma By Dr. Osman Sadig Bukhari
  3. 3. <ul><li>The reticular activating substance influence the state of arousal. Our state of consciousness is the product of complex interactions between parts of reticular formation itself, cortex and brainstem and sensory </li></ul><ul><li>stimuli reaching them. </li></ul>
  4. 4. <ul><li>Coma :- is a state in which za pt is unrousable and unresponsive to external stimuli </li></ul><ul><li>- Glasgow Coma Scale (GCS) is </li></ul><ul><li>used for grading coma. </li></ul><ul><li>- It has many causes which should </li></ul><ul><li>be investigated and treated </li></ul><ul><li>- Diagnostic workup of comatosed </li></ul><ul><li>pt. must proceed concomitantly </li></ul><ul><li>with management. </li></ul>
  5. 5. <ul><li>Glasgow Coma Scale (GCS) </li></ul><ul><li>Eye opening (E): </li></ul><ul><li>Spontaneous 4 </li></ul><ul><li>To speech 3 </li></ul><ul><li>To pain 2 </li></ul><ul><li>No response 1 </li></ul><ul><li>Motor response (M) </li></ul><ul><li>Obeys 6 </li></ul><ul><li>localizes 5 </li></ul><ul><li>Withdraws 4 </li></ul><ul><li>flexion 3 </li></ul><ul><li>Extension 2 </li></ul><ul><li>No response 1 </li></ul>
  6. 6. <ul><li>Verbal response (V) </li></ul><ul><li>Oriented 5 </li></ul><ul><li>Confused conversation 4 </li></ul><ul><li>Inappropriate words 3 </li></ul><ul><li>Incomprehensive sounds 2 </li></ul><ul><li>No response 1 </li></ul><ul><li>GCS= E+M+V </li></ul><ul><li>- 50% of pts wz score of 4 or less will die </li></ul><ul><li>- Death is rare wz score of 13 or more </li></ul><ul><li>- GCS should be assessed every ½-2 hrs. </li></ul>
  7. 7. <ul><li>Mechanism of coma: </li></ul><ul><li>1- diffuse brain dysfn as in metabolic and </li></ul><ul><li>toxic disorders which depress brain fn. </li></ul><ul><li>2- lesions within za brainstem which </li></ul><ul><li>damage za reticular activating system </li></ul><ul><li>3- pressure effect on za brainstem from </li></ul><ul><li>mass lesions inhibiting za reticular </li></ul><ul><li>activating system </li></ul>
  8. 8. <ul><li>Causes of coma: </li></ul><ul><li>1- Head injury ( extradural hage, SDH and </li></ul><ul><li>cerebral contusion) </li></ul><ul><li>2- Infections : - cerebral malaria </li></ul><ul><li>- meningitis </li></ul><ul><li>- encephalitis, African trypan </li></ul><ul><li>3- Endocrine :- diabetes M:- hypoglycemia </li></ul><ul><li>- DKA </li></ul><ul><li>- hyper osmolar </li></ul><ul><li>- hypothyroidism </li></ul><ul><li>- hypopituitarism </li></ul><ul><li>- hypoadrenalism. </li></ul>
  9. 9. <ul><li>4- Metabolic:- hypo & hyper natraemia </li></ul><ul><li>- hypo & hyper calcemia. </li></ul><ul><li>- metabolic acidosis </li></ul><ul><li>- renal, hepatic & resp failure </li></ul><ul><li>- porphyria </li></ul><ul><li>- thiamine deficiency. </li></ul><ul><li>5- Toxins & drug overdose:- </li></ul><ul><li>- alcohol </li></ul><ul><li>- CO poisoning </li></ul><ul><li>- barbiturates, etc. </li></ul><ul><li>6- Epilepsy </li></ul><ul><li>7- Cerebrovascular diseases . </li></ul>
  10. 10. <ul><li>8- Heat stroke, hypothermia, hypoxia </li></ul><ul><li>9- Intracranial mass lesions </li></ul><ul><li>10- Psychogenic </li></ul>
  11. 11. <ul><li>Immediate assessment and </li></ul><ul><li>Emergency measures: </li></ul><ul><li>1- Position: pt on one side wz za neck </li></ul><ul><li>partly extended. </li></ul><ul><li>2- Ensure A irway , B reathing & C irculation </li></ul><ul><li>5- Dextrose 50% </li></ul><ul><li>6- Head injury : observe & investigate </li></ul><ul><li>7- Spinal injury : immobilize. </li></ul><ul><li>8- Take blood for sugar, electrolytes, Ca </li></ul><ul><li>renal & hepatic fn, blood gases, toxicol </li></ul><ul><li>9- Document degree of coma using GCS </li></ul>
  12. 12. <ul><li>Further steps to identify za cause : </li></ul><ul><li>1- History taken from a relative, eye wittn </li></ul><ul><li>or policeman </li></ul><ul><li>- Look for identification card, wrist band </li></ul><ul><li>or necklace e.g. diabetics, epileptics </li></ul><ul><li>and pts on C/S. </li></ul><ul><li>- Onset of coma & time course of </li></ul><ul><li>subsequent events. </li></ul><ul><li>- History head injury & subsequent </li></ul><ul><li>course. </li></ul><ul><li>- History of fever . </li></ul>
  13. 13. <ul><li>- PMH : DM, epilepsy, renal, hepatic and </li></ul><ul><li>endocrine dis, psychiatric illness </li></ul><ul><li>- Social & drug history : insulin, oral hypo </li></ul><ul><li>2- General medical exam in comatosed pt: </li></ul><ul><li>- Evidence of social decline </li></ul><ul><li>- Evidence of trauma </li></ul><ul><li>- Temperature </li></ul><ul><li>- S kin & mucous membranes e.g. pallor </li></ul><ul><li>jaundice, cyanosis, purpura, injection </li></ul><ul><li>marks, sweats, texture (dry & coarse </li></ul><ul><li>in hypothyr), rash, pigmentation. </li></ul>
  14. 14. <ul><li>- B reath : for alcohol, acetone, hepatic </li></ul><ul><li>and uraemic fetor. </li></ul><ul><li>- R espiration :- Kussmaul breathing. </li></ul><ul><li>- Chyne Stokes breathing </li></ul><ul><li>- Central neurogenic </li></ul><ul><li>hypervent in pontine lesi </li></ul><ul><li>(deep & rapid breathing) </li></ul><ul><li>- ataxic resp : shallow, halt </li></ul><ul><li>irregular resp. wz medull </li></ul><ul><li>resp centre damage & usually preceeds death </li></ul>
  15. 15. <ul><li>- G eneral systemic exam . </li></ul><ul><li>3- Neurological exam in comatosed pt : </li></ul><ul><li>a- H ead, neck & spine </li></ul><ul><li>b- Pupil size & reaction to light </li></ul><ul><li>- unilateral light fixed dilated pupil= coning of za uncus (compress of 3) </li></ul><ul><li>- bilateral light fixed dilated </li></ul><ul><li>pupil= brain stem death, deep </li></ul><ul><li>coma from barbit, hypoth. </li></ul><ul><li>- unilat. small pupil + ptosis= Horners </li></ul><ul><li>- bilateral pin point light fixed pupils </li></ul><ul><li>= pontine hage, opiate poisoning </li></ul>
  16. 16. <ul><li>-bilateral mid point reactive pupils=metab </li></ul><ul><li>and CNS depressants except opiat </li></ul><ul><li>c- Ocular movements </li></ul><ul><li>- sustained conjugate lateral deviation </li></ul><ul><li>occurs towards za side of a destructive </li></ul><ul><li>frontal lesion </li></ul><ul><li>- dysconjugate deviation= structural brainstem lesion </li></ul><ul><li>- oculocephalic response (dolls head reflx </li></ul><ul><li>is lost in deep coma & BD </li></ul><ul><li>- caloric or vestibulo-ocular reflex is lost </li></ul><ul><li>in coma due to BD. </li></ul>
  17. 17. <ul><li>- skew deviation= brain stem or cerebell </li></ul><ul><li>lesions. </li></ul><ul><li>- ocular bobbing= pontine or cerebell les </li></ul><ul><li>d- Fundi: for papilloedema & haemorrhage </li></ul><ul><li>e- Lateralizing signs </li></ul><ul><li>- facial asymmetry </li></ul><ul><li>- tone </li></ul><ul><li>- asymmetric response to painful stimul </li></ul><ul><li>- asymmetry of planter response </li></ul><ul><li>- asymmetry of reflexes </li></ul><ul><li>- asymmetry of decorticate or </li></ul><ul><li>decerebrate posturing. </li></ul>
  18. 18. <ul><li>Investigation of comatosed pt </li></ul><ul><li>- BFM - Urine ex. - CBC </li></ul><ul><li>- blood biochemstry </li></ul><ul><li>- Endocrine - Toxicology </li></ul><ul><li>- ECG & CXR </li></ul><ul><li>- immaging - EEG - ABG </li></ul><ul><li>- CSF - blood culture </li></ul>
  19. 19. <ul><li>Management of comatosed pt </li></ul><ul><li>1- careful nursing </li></ul><ul><li>2- attention to A irway, B reathing & C ircul </li></ul><ul><li>3- IV canulae & fluids </li></ul><ul><li>4- NG tube & feeding (calories) </li></ul><ul><li>5- catheterization </li></ul><ul><li>6- frequent monitoring & charting of </li></ul><ul><li>vital signs. </li></ul><ul><li>7- skin care & oral hygiene </li></ul><ul><li>8- care of za eye </li></ul><ul><li>9- treat za CAUSE. </li></ul>
  20. 20. <ul><li>Brain death (BD) </li></ul><ul><li>- Death= no spontaneous resp or heart </li></ul><ul><li>beat. </li></ul><ul><li>- BD should be considered in deeply </li></ul><ul><li>comatosed ventilated pts in whom </li></ul><ul><li>curable causes have been excluded. </li></ul><ul><li>- Criteria are laid down before pt put off </li></ul><ul><li>ventilator & organs taken for donation. </li></ul>
  21. 21. <ul><li>Pre conditions for diagnosis of BD </li></ul><ul><li>1- Patient deeply comatosed </li></ul><ul><li>2- Patient inadequately breathing or has </li></ul><ul><li>ceased breathing & put on mechanical </li></ul><ul><li>ventilator i.e. NO spont breathing if pt put off ventilator long enough (CO2 tension 6.7 kp= 50mm Hg) </li></ul><ul><li>3- NO drug is responsible for coma including N/M blocking agents, sedatives or anticonvulsants. </li></ul><ul><li>4- NO hypothermia (rectal temp >35) </li></ul>
  22. 22. <ul><li>5- NO metabolic or endocrine cause of coma. No profound abn of plasma E and acid- base balance or blood glucose level. 6- Evidence of irremediable structural brain damage e.g. head injury intracranial hage. </li></ul><ul><li>7-The diag should be confirmed by 2 </li></ul><ul><li>experienced Drs: two consultants or </li></ul><ul><li>at least one consultant & senior registr </li></ul><ul><li>and tests of BD repeated in 24 hrs </li></ul><ul><li>before final diag. </li></ul><ul><li>* Diag of BD: stop vent & other life suppor </li></ul><ul><li>measures. Organ taken for trnaspl . </li></ul>
  23. 23. <ul><li>Confirmatory tests for BD </li></ul><ul><li>All brain stem reflexes are absent . </li></ul><ul><li>Tests : NOT performed in the presence of seizure or abnormal </li></ul><ul><li>posture. Seizures & rigidity are not consistent with BD. </li></ul><ul><li>1- light fixed pupils (usually dilated) </li></ul><ul><li>2- no gag or cough reflex (oropharyngeal) </li></ul><ul><li>3- absent corneal reflexes . </li></ul><ul><li>4- absent vestibulo ocular reflex </li></ul><ul><li>5- absent oculocephalic reflexes </li></ul><ul><li>6- no motor response within cranial nerve territory to painful stimuli. Spinal reflexes may be present . 7- no resp effort when pt off ventilator . </li></ul>
  24. 24. <ul><li>7- EEG is not pre requisite for diag of BD </li></ul><ul><li>8- Neurological or neurosurgical opinion when the primary cause of BD is in doubt. </li></ul>

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