Alteration of consciousness2

46
Alteration of Alteration of Consciousness Consciousness

Transcript of Alteration of consciousness2

Page 1: Alteration of consciousness2

Alteration of ConsciousnessAlteration of Consciousness

Page 2: Alteration of consciousness2

Reticular activating system (RAS)

Page 3: Alteration of consciousness2

Good ConsciousnessGood Consciousness = =

Alertness + Awareness Alertness + Awareness

Page 4: Alteration of consciousness2

Diminished alertnessDiminished alertness = =

Widespread abnormalities of cerebral Widespread abnormalities of cerebral

hemispheres or reduced activity of hemispheres or reduced activity of reticular reticular

activating system (RAS)activating system (RAS)

Page 5: Alteration of consciousness2

Definition of TermsDefinition of Terms

Confusion : Confusion : – impaired attentionimpaired attention and concentration, manifest and concentration, manifest

disorientation in time, place and persondisorientation in time, place and person, impersistent , impersistent thinking, speech and performance, reduced thinking, speech and performance, reduced comprehension and capacity to reasoncomprehension and capacity to reason

– Fluctuate in severity, typically worse at night Fluctuate in severity, typically worse at night ‘sundowning’‘sundowning’

– Perceptual disturbances and misinterpret voices, Perceptual disturbances and misinterpret voices, common objects and actions of other personscommon objects and actions of other persons

Confusion is also found in dementia (progressive Confusion is also found in dementia (progressive failure of language, memory, and other intellectual failure of language, memory, and other intellectual functions)functions)

Page 6: Alteration of consciousness2

Definition of TermsDefinition of Terms

Delirium : confusion and associated Delirium : confusion and associated agitation, hallucination, convulsion and agitation, hallucination, convulsion and tremortremor

Amnesia : a loss of past memories and to Amnesia : a loss of past memories and to an ability to form new ones, despite alert an ability to form new ones, despite alert and normal attentivenessand normal attentiveness

Page 7: Alteration of consciousness2

Level of Consciousness(1)Level of Consciousness(1)

Alert  : Alert  : normal awake and responsive statenormal awake and responsive state Drowsiness Drowsiness :: state of apparent sleep, briefly state of apparent sleep, briefly

arousal with oral commandarousal with oral command

Lethargic Lethargic :: resembles sleepiness, but not resembles sleepiness, but not becoming fully alert, slow verbal response becoming fully alert, slow verbal response and inattentive. Unable to adequately and inattentive. Unable to adequately perform simple concentration task (such as perform simple concentration task (such as counting 20 to 1)counting 20 to 1)

Page 8: Alteration of consciousness2

Level of Consciousness (2)Level of Consciousness (2) Somnolent :  easily aroused by voice or touch; aw

akens and follows commands; required stimulation to maintain arousal

Obtunded/Stuporous : arousable only with repeated and painful stimulation; verbal output is unintelligible or nil; some purposeful movement to noxious stimulation

Comatose : no arousal despite vigorous stimulation, no purposeful movement- only posturing, brainstem reflexes often absent

Page 9: Alteration of consciousness2

Dementia VS Confusional stateDementia VS Confusional state

DementiaDementia– Longstanding natureLongstanding nature

– Varies little from time to Varies little from time to timetime

– Memory problemMemory problem

Confusional stateConfusional state– AcuteAcute

– FluctuateFluctuate

– Clouding of Clouding of consciousnessconsciousness

Page 10: Alteration of consciousness2

Causes of confusional state(1)Causes of confusional state(1)

Medical or surgical diseaseMedical or surgical disease Metabolic disorders Metabolic disorders

– HepaticHepatic– UremicUremic– Hypo and hypernatremiaHypo and hypernatremia– HypercalcemiaHypercalcemia– Hypo and hyperglycemiaHypo and hyperglycemia– HypoxiaHypoxia– HypercapniaHypercapnia

Page 11: Alteration of consciousness2

Causes of confusional state(2)Causes of confusional state(2)

Infectious illnessInfectious illness– PneumoniaPneumonia– EndocarditisEndocarditis– Urinary tract infectionUrinary tract infection– PeritonitisPeritonitis

Congestive heart failureCongestive heart failure Postoperative and posttraumatic statesPostoperative and posttraumatic states

Page 12: Alteration of consciousness2

Causes of confusional state(3)Causes of confusional state(3)

Drug intoxicationDrug intoxication

OpiatesOpiates BarbituratesBarbiturates Other sedativesOther sedatives

Page 13: Alteration of consciousness2

Causes of confusional state(4)Causes of confusional state(4)

Diseases of nervous systemDiseases of nervous system Cerebrovascular disease, tumor, abscessCerebrovascular disease, tumor, abscess Subdural hematomaSubdural hematoma MeningitisMeningitis EncephalitisEncephalitis Cerebral vasculitisCerebral vasculitis Hypertensive encephalopathyHypertensive encephalopathy

Page 14: Alteration of consciousness2

ApproachApproach

HistoryHistory --- emphasizing the patient’s --- emphasizing the patient’s condition before the onset of confusioncondition before the onset of confusion

Clinical examinationClinical examination --- focus on --- focus on – signs of diminished attentiveness, signs of diminished attentiveness,

disorientation, and drowsiness and disorientation, and drowsiness and – the presence of localizing neurological signsthe presence of localizing neurological signs

Page 15: Alteration of consciousness2

Aim of careAim of care in confusion patientsin confusion patients

Control underlying medical illnessControl underlying medical illness Quiet the patient and protect him from injuryQuiet the patient and protect him from injury

- Discontinue drugs that could possibly be Discontinue drugs that could possibly be responsible for the acute confusional state : responsible for the acute confusional state : sedating, antianxiety, narcotic, anticholinergic, sedating, antianxiety, narcotic, anticholinergic, antispasticity, corticosteroid, L-dopa, antispasticity, corticosteroid, L-dopa, metoclopramide, cimetidine, antidepressant, metoclopramide, cimetidine, antidepressant, antiarrhythmic,anticonvulsant, antibiotics.antiarrhythmic,anticonvulsant, antibiotics.

Page 16: Alteration of consciousness2

Medical managementMedical management

- Haloperidol, quetiapine, risperidone are Haloperidol, quetiapine, risperidone are helpful in calming the agitated and helpful in calming the agitated and hallucinating patient, but should be used in hallucinating patient, but should be used in the lowest effective dosesthe lowest effective doses

- In alcohol or sedative withdrawal—In alcohol or sedative withdrawal—chlordiazepoxide is the drug of choice. chlordiazepoxide is the drug of choice. Chloral hydrate, lorazepam, and diazepam Chloral hydrate, lorazepam, and diazepam are equally effectiveare equally effective

Page 17: Alteration of consciousness2

COMACOMA

Page 18: Alteration of consciousness2

GLASGOW COMA SCOREGLASGOW COMA SCOREEye opening:Eye opening:

NilNil 11To pain (applied to limbs)To pain (applied to limbs) 22To voice (including command)To voice (including command) 33Spontaneous (with Spontaneous (with blinkingblinking)) 44

Motor response:Motor response:NilNil 11Arm extension to pain (nail bed pressure)Arm extension to pain (nail bed pressure) 22Arm flexion to pain (nail bed pressure)Arm flexion to pain (nail bed pressure) 33Arm withdrawal from pain (nail bed pressure)4Arm withdrawal from pain (nail bed pressure)4Hand localizes pain(supraorbital or chest pressure)5Hand localizes pain(supraorbital or chest pressure)5Obeys commandsObeys commands 66

Verbalize response:Verbalize response:NILNIL 11Groans (no re-cognizable words)Groans (no re-cognizable words) 22Inappropriate words (including expletives)Inappropriate words (including expletives) 33Confused speechConfused speech 44OrientatedOrientated 55

Page 19: Alteration of consciousness2

Glasgow Coma Scale : Eye opening (E)

Page 20: Alteration of consciousness2

Glasgow Coma Scale : Motor response (M)

Page 21: Alteration of consciousness2

Glasgow Coma Scale : Verbal response (V)

Page 22: Alteration of consciousness2

NotesNotes

1.1. scoring from the best response scoring from the best response

2.2. verbal response will not correct in the condition verbal response will not correct in the condition of aphasia, intubation andof aphasia, intubation and facial facial injuryinjury

3.3. sensory loss may interfere painful stimulation sensory loss may interfere painful stimulation

4.4. eye opening may be interfered by orbital swelling eye opening may be interfered by orbital swelling and 3and 3rdrd CN palsy CN palsy

5.5. arm movements may be impaired from local arm movements may be impaired from local trauma or cervical cord lesion trauma or cervical cord lesion

GLASGOW COMA SCOREGLASGOW COMA SCORE

Page 23: Alteration of consciousness2

Approach to the patientApproach to the patient

HistoryHistory– Circumstances and rapidity with which Circumstances and rapidity with which

neurologic symptoms developedneurologic symptoms developed– Immediately preceding medical and neurologic Immediately preceding medical and neurologic

symptomssymptoms– Use of medications, illicit drugs, or alcoholUse of medications, illicit drugs, or alcohol– Chronic liver, kidney, lung, heart, or other Chronic liver, kidney, lung, heart, or other

medical diseasemedical disease

Page 24: Alteration of consciousness2

General physical examinationGeneral physical examination

Vital signVital sign– TemperatureTemperature

FeverFever Hypothermia -- <31Hypothermia -- <31°C causes coma°C causes coma

– PulsePulse– Respiratory rate and patternRespiratory rate and pattern– Blood pressureBlood pressure

Funduscopic examinationFunduscopic examination Cutaneous lesionCutaneous lesion

Page 25: Alteration of consciousness2

Neurologic assessmentNeurologic assessment

ObserveObserve– Movement : restless, twitching, multifocal Movement : restless, twitching, multifocal

myoclonus, asterixismyoclonus, asterixis– Decorticate rigidity Decorticate rigidity

Suggest severe bilateral damage rostral to Suggest severe bilateral damage rostral to midbrainmidbrain

– Decerebrate rigidity Decerebrate rigidity

Indicate damage to motor tracts in the midbrain or Indicate damage to motor tracts in the midbrain or caudal diencephaloncaudal diencephalon

Page 26: Alteration of consciousness2

Decorticate posture results from Decorticate posture results from damage to one or both corticospinal damage to one or both corticospinal

tractstracts

Page 27: Alteration of consciousness2

Decerebrate posture results from Decerebrate posture results from damage to the upper brain stemdamage to the upper brain stem

Page 28: Alteration of consciousness2

Neurologic assessmentNeurologic assessment

Level of arousal and elicited movementsLevel of arousal and elicited movements Brainstem reflexes Brainstem reflexes

– pupilspupils– Ocular movementsOcular movements– respirationrespiration

Page 29: Alteration of consciousness2

Pupils in comatose patientsPupils in comatose patients

DESCRIPTIONSDESCRIPTIONSINTERPRETATIONINTERPRETATION

Small, reactiveSmall, reactive Metabolic causesMetabolic causesDiencephalic lesionDiencephalic lesion

Midposition, fixedMidposition, fixed Mid brain lesionMid brain lesion

large, fixedlarge, fixed Extensive brain stem lesion Extensive brain stem lesion AAnoxianoxiaSSedative overdoseedative overdose

AAnticholinergic poisoning or nticholinergic poisoning or mydriatic mydriatic eyedropseyedrops Pin pointPin point Pontine lesionPontine lesion OpiatesOpiates

Unilateral fixed dilatedUnilateral fixed dilated TThird nerve palsyhird nerve palsy

Page 30: Alteration of consciousness2
Page 31: Alteration of consciousness2

Doll’s eye Doll’s eye maneuver maneuver

(Oculocephalic (Oculocephalic reflex)reflex)

Cold caloric test Cold caloric test (Oculovestibular (Oculovestibular

reflex) reflex)

Page 32: Alteration of consciousness2
Page 33: Alteration of consciousness2

Eye movementsEye movements

ConditionCondition

AwakeAwake

Cerebral dysfunction, Cerebral dysfunction, brainstem intactbrainstem intact

Brain stem lesionBrain stem lesion

Doll’s eyesDoll’s eyes

NegativeNegative

Positive Positive

NegativeNegative

ConditionCondition

AwakeAwake

Cerebral dysfunction, Cerebral dysfunction, brainstem intactbrainstem intact

Brain stem lesionBrain stem lesion

Cold caloricsCold calorics

Nystagmus, N/V, painNystagmus, N/V, pain

Slow deviation toward Slow deviation toward waterwater

NegativeNegative

Page 34: Alteration of consciousness2

Respiratory patterns

Page 35: Alteration of consciousness2

Respiratory pattern(1)Respiratory pattern(1) Cheyne-Stokes respiration : bilateral cortical or Cheyne-Stokes respiration : bilateral cortical or

bilateral thalamic lesions, metabolic bilateral thalamic lesions, metabolic disturbances, incipient transtentorial herniationdisturbances, incipient transtentorial herniation

Hyperventilation : midbrain or pons lesionsHyperventilation : midbrain or pons lesions Apneusis : lateral tegmentum of lower half of Apneusis : lateral tegmentum of lower half of

ponspons Cluster : lower pontine or high medullary Cluster : lower pontine or high medullary

lesionslesions Ataxic : dorsomedial medulla lesion Ataxic : dorsomedial medulla lesion

Page 36: Alteration of consciousness2

Respiratory pattern(2)Respiratory pattern(2)

Least useful sign because :Least useful sign because :– Acid-base derangementsAcid-base derangements

– HypoxiaHypoxia

– Cardiac influencesCardiac influences

Page 37: Alteration of consciousness2

Conditions mimic comaConditions mimic coma

Brain deathBrain death Locked-in syndromeLocked-in syndrome Vegetative state Vegetative state Frontal lobe disease Frontal lobe disease Non-convulsive status epilepticus Non-convulsive status epilepticus Psychiatric disorder (catatonia, Psychiatric disorder (catatonia,

depression)depression)

Page 38: Alteration of consciousness2

Vegetative stateVegetative state

An An awake but unresponsive stateawake but unresponsive state Extensive damage in both cerebral Extensive damage in both cerebral

hemispherehemisphere Retained respiratory and autonomic Retained respiratory and autonomic

functionsfunctions Cardiac arrest and head injuryCardiac arrest and head injury are the most are the most

common causes.common causes.

Page 39: Alteration of consciousness2

Locked-in stateLocked-in state

AwakeAwake patient has patient has no means of no means of producing speech or volitional limb, producing speech or volitional limb, face and pharyngeal movementsface and pharyngeal movements

Vertical eye movement and lid Vertical eye movement and lid elevation remain unimpairedelevation remain unimpaired

Infarction or hemorrhage of the ventral Infarction or hemorrhage of the ventral ponspons

Page 40: Alteration of consciousness2

COMACOMA

LOCALIZING SIGN NO LOCALIZING SIGN

SUPRATENTORIAL INFRATENTORIAL

NO STIFF NECK

STIFF NECK

- CVD- TUMOUR- ABSCESS

STRUCTURAL DAMAGE FUNCTIONAL NEURONAL DEPRESSION

- HYPOXIA

- CARDIAC ARREST

- ENCEPHALITIS

- HEPATIC- URAEMIC- POST ICTAL STATE- FLUID ELECTROLYTE IMBALANCE- DRUGS

- SAH

- MENINGITIS

Page 41: Alteration of consciousness2

Blood testBlood test

CBCCBC FBSFBS BUN, CreatinineBUN, Creatinine Electrolyte, calciumElectrolyte, calcium LFTLFT Drug screen, toxicology screenDrug screen, toxicology screen

Page 42: Alteration of consciousness2

Other testsOther tests

EKGEKG CT or MRI brainCT or MRI brain CSF examCSF exam EEGEEG

Page 43: Alteration of consciousness2

Prognosis of comaPrognosis of coma

Recovery from coma depends primarily on the causes, rather than on the depth of coma

Intoxication and metabolic causes carry the best prognosis

Coma from traumatic head injury far better than those with coma from other structural causes

Coma from global hypoxic-ischemic carries least favorable prognosis

At 3rd day, no papillary light reflex or GCS < 5 is associated with poor prognosis

Page 44: Alteration of consciousness2

Brain HerniationBrain Herniation

Central Central transtentorial transtentorial herniationherniation

Page 45: Alteration of consciousness2

Uncal Uncal transtentorial transtentorial herniationherniation

Brain HerniationBrain Herniation

Page 46: Alteration of consciousness2

Management of Transtentorial Management of Transtentorial herniationherniation

Intubation andIntubation and hyperventilation (Phyperventilation (PCOCO22 25-30 25-30

mmHg)mmHg)

Mannitol (0.5-1 gm/kg body weight orMannitol (0.5-1 gm/kg body weight or 2020%%

mannitol 200 cc. infusion 10-20 minutes repeat mannitol 200 cc. infusion 10-20 minutes repeat

every 4 hours if necessary every 4 hours if necessary

Furosemide Furosemide 20-4020-40 mg IVmg IV

Dexamethasone 4-10 mg IV q 6 hours Dexamethasone 4-10 mg IV q 6 hours

decrease perilesional vasogenic cerebral decrease perilesional vasogenic cerebral

edema. Active at 24-48 hours.edema. Active at 24-48 hours.

Consult surgery Consult surgery