ALTERED MENTAL STATUS & COMA

Dr makeldin

DESCRIPTIONS

• Unarousable unresponsiveness• Light Coma• Deep Coma• Loss of either arousal or cognititon• Stupor• Obtundation• Clouding of consciousness

GLASGOW COMA SCALE E : Eye OpeningV : Best Verbal ResponseM : Best Motor Response

total scoring

-> Open

* Spontaneously 4

* To Verbal 3

* To Pain 2

-> No response 1

EYE OPENING

BEST VERBAL RESPONSE

- Oriented & converses 5

- Disoriented & converses 4

- Verbalizes 3

- Vocalizes 2

- No response 1

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 – AlertV – Response to Verbal stimuliP – Response to Pain stimuliU - 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 – AlcoholE – Endocrine / ElectrolytesI – InsulinO - Opiate / OxygenU - Uremia

A E I O U ?

T I P S ?

T – Toxin / trauma / temperatureI – InfectionsP – Psych / PorphyriaS – SAH, stroke, shock, space occupying lesion

Usually stuporousBlood 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

HypoglycemiaAdult Plasma < 45mg/dlChild < 40mg/dl

HyperglycemiaGlucose > 600 + OSM > 340

O – OPIATES / OXYGEN

* Meperidine,opiate,codeine, morphine,cocaine etc

* CO2 retension + acidosis Hypoxia

U – UREMIA

BUN sudden increase > 60mg/100ml

T- Toxin /Trauma/Temperature

Toxin –- Hypnotic agent, barbiturateTrauma –- multi-factorialTemperature –- *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/thromboticShock: hypovolemic/obstructive, cardiogenic/vasogenic/anaphylatic pharmacologic/neurogenic

CLINICAL PRESENTATION ?

Hypothermia

- Infection, hypoglycemia, myxedema coma, alcohol & sedative overdose.

Fever

- Infection, thyrotoxicosis, sympathomimetic, hypothalamic, hemorrhage, anticholinergics, neuroleptic malignant syndrome.

Hypertension

- structural lesion, HTN encephalopathyHypotension- systemic disease, sepsis

HEENT

Mydriasis- organophosphateMiosis- narcotic, anticholinergic, potine lesionLoss of pupillary reflex or anisocoria- structural lesionEvidence 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

Naloxone ( Narcan )

0.4-2mg IV Q2-3min

Long acting :

•Nalmefene

•Naltrexone

Hypoglycemia

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

THE END