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ALTERED MENTAL STATUS & COMA Dr  makeldin
DESCRIPTIONS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
GLASGOW COMA SCALE   E : Eye Opening V : Best Verbal Response M : Best Motor Response  total scoring
->  Open * Spontaneously  4 * To Verbal  3 * To Pain  2 ->  No response 1 EYE OPENING
BEST VERBAL RESPONSE ,[object Object],[object Object],[object Object],[object Object],[object Object]
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
* 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
Glasgow Coma Scale  Score of 8 or less COMA  
Advanced Trauma Life Support (ATLS)  Level of consciousness-- AVPU A – Alert V – Response to Verbal stimuli P – Response to Pain stimuli U - Unconscious
Altered Mental Status ?   What are the causes of
Emergency Medicine Mnemonic in  Altered Mental Status  A E I O U T I P S
A – Alcohol E – Endocrine / Electrolytes I – Insulin O - Opiate / Oxygen U - Uremia  A E I O U  ?
T I P S  ? T – Toxin / trauma / temperature I  – Infections P – Psych / Porphyria S – SAH, stroke, shock,   space occupying lesion
Usually stuporous Blood alcohol > 200mg/dl A - ALCOHOL
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
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)
I – INSULIN   Hypoglycemia Adult Plasma < 45mg/dl Child < 40mg/dl Hyperglycemia Glucose > 600 + OSM > 340
O – OPIATES / OXYGEN   * Meperidine,opiate,codeine, morphine,cocaine etc * CO 2  retension + acidosis Hypoxia
U – UREMIA   BUN sudden increase > 60mg/100ml
T- Toxin /Trauma/Temperature Toxin –-  Hypnotic agent, barbiturate Trauma –- multi-factorial Temperature –-  *Hyperthermia > 40.5 c *Hypothermia  < 32 c
I : INFECTIONS CNS & Systemic Infection
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.
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
CLINICAL PRESENTATION ?
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
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
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
Treatment in ER
Initial Stabilization A - Airway B – Breathing C – Circulation
E D TREATMENT B A N G
B :  B1 Vitamin A : Anexate N : Naloxone G :  Glucose
Wernicke’s Encephalopathy Confusion, apathy, drosiness, ataxic, nystagmus, ophthalmoplegia. Cause : chronic alcohol abuse & thiamine deficiency Tx : Thiamine IV  Alinamine F, Nutrase
Flumazenil ( Anexate ) 0.2 mg IV over 15 sec. Also effective in Hepatic coma
[object Object],[object Object],[object Object],[object Object],[object Object]
Hypoglycemia * Give 20-50g of 50% Glucose. * Then constant IVF glucose    till pt can take by mouth.
THE END

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Coma

  • 1. ALTERED MENTAL STATUS & COMA Dr makeldin
  • 2.
  • 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
  • 5.
  • 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. * &quot;coma is a state of unresponsiveness from which an individual has not yet been aroused &quot; . 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
  • 25.
  • 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
  • 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
  • 34.
  • 35. Hypoglycemia * Give 20-50g of 50% Glucose. * Then constant IVF glucose till pt can take by mouth.