1. The document discusses various conditions that cause altered mental status including coma, acute confusional state (delirium), and status epilepticus. 2. Coma is defined as a GCS of 8 or lower caused by disorders of the ascending reticular activating system or cerebral cortex. The most common causes are metabolic disorders, drugs/toxins, and mass lesions. 3. Acute confusional state is also known as delirium, characterized by acute cognitive impairment and symptoms like disordered thinking and altered sleep cycles. It has numerous potential medical, toxic, infectious, or metabolic causes.

1. COMA
ACUTE CONFUSIONAL STATE
STATUS EPILECTICUS

2. COMA
1. A state of unarousable unresponsiveness, defined
as GCS of 8 or lower.
2. Consciousness is dependent on the functioning of :
• The ascending reticular activation system (ARAS)
projecting from brainstem to thalamus: determines
level of consciousness.
• The cerebral cortex: determines the content of
consciousness.

3. The commonest
cause of coma are
metabolic disorders
(35%), drugs/toxins
(25%), mass lesions
(20%) .

4. The Unconscious Patient: Immediate
Assessment
General Examination.
•Airway, breathing and
circulation.
•Dextrostix for blood
glucose.
•Treat seizures (if present)
with buccal midazolam or
IV phenytoin if not
terminated.
•Measure temperature
and check for meningism.
•Sniff patient’s breath for
ketones, alcohol and
hepatic fetor.
•Survey skin for signs of
trauma/spinal injury, rash
(meningococcal sepsis),
stigmata of liver disease.
•Check respiratory
pattern: Cheyne-Stokes,
Kussmaul
Neurological examination
•Glasgow Coma Scale
•Fundus: papilloedema
•Brainstem function
•Pupils size and reaction
to light.
•Eye movements and
position
•Vestibulo-ocular reflex
•Ocular reflex
•Gag reflex
Investigations
•Blood and urine
•Drugs screening: blood
alcohol, urine screening
for BDZ, opioids and
amphetamines.
•Biochemistry: BUSE, LFT,
glucose, Serum Ca
•Metabolic and
endocrine: TSH, cortisol
•Arterial blood gases:
TRO acidosis or high
CO2 level.
•CT Brain
•CSF Analysis

5. General Management
• Comatose patients need careful nursing, meticulous attention
to the airway, and frequent monitoring of vital functions.
• Longer-term essentials are:
– Skin care – turning (to avoid pressure sores and pressure palsies).
– Oral hygiene – mouthwashes, suction.
– Eye care – prevention of corneal damage (lid taping, irrigation).
– Fluids – nasogastric or i.v.
– Feeding – via a fine-bore nasogastric tube or via peg.
– Sphincters – catheterization when essential (use penile urinary sheath
if possible in men); rectal evacuation.

7. ACUTE CONFUSIONAL STATE
• a.k.a delirium.
• Acute cognitive impairment, acute encephalopathy,
acute brain failure
• Transient disorder with impairment of attention and
cognition

8. 8 Signs of Delirium
Disordered thinking: slow irrational rambling, jumble up,
incoherent ideas
Euphoric, fearful, depressed or angry
Language impaired
Illusion, delusion, hallucination: tactile/ visual
Reversal of sleep cycle (drowsy by day and hypervigilant by night)
Inattention
Unaware, disoriented
Memory deficits

9. •CNS disorder:
Vascular: hemorrhage, hypertensive encephalopathy
Infections: meningitis, encephalitis
Nutritional deficiency: thiamine, B12
Head trauma, epilepsy, degenerative
•Metabolic :
hepatic/renal failure, hypoxia, electrolyte imbalance, hypoglycemia
•Endocrinal:
hypo/hyperthyrodism, adrenal crisis
•Cardiopulmonary :
MI,CHF, respiratory failure, shock
•Toxins:
Opiods, Carbon Monoxide
•Substance abuse
CAUSES

11. Diagnosis
History:
•Situation patient found in
•Baseline cognitive function
•Time course
•Current medication
•Screening for symptoms of
organ failure/systemic infection
•History of illicit drug use,
alcoholism or toxin exposure
Physical examination:
•General physical examination
•Signs of infection, fluid status,
skin appearance
•Exclusion of other psychiatrics
disorders associated with
delirium, neurodegenerative
condition

12. Investigations:
• Basic screening for systemic
infection
• Serum urine drug and
toxicology
• Additional laboratory tests
(autoimmune, endocrinology,
metabolic and infectious
etiology)
Management
1. Acute mx
• Patients pose threat to own safety
and staff members
• Bed alarms and personal sitters
• Physical restrains
• Chemical restrains
Haloperidol 5-10mg at 20-30mins
intervals
Midazalam 0.5-2 mg
2. Chronic
• Tx of underlying factor
• Do not exacerbate confusion
• Avoid sedatives

15. Status epilepticus
Seizure not resolving spontaneously, OR recurrent
seizure without recovery of consciousness in between,
lasting more than 5 minutes
Causes:
1) subtherapeutic anti-epileptic drug level (pre
existing epilepsy)
2) de novo (exclude infection, neoplasia, metabolic
derangement)

16. Clinical diagnosis:
•prolonged rigidity
•clonic movement
•loss of awareness
•cyanosis
•pyrexia
•acidosis
•sweating
Complication:
•aspiration
•hypotension
•arrhythmias
•renal or hepatic failure

17. Davidson Essential of Medicine.

18. • Refer Guideline page 57.