Altered Consciousness
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Transcript of Altered Consciousness
بسم الله الرحمن الرحيمبسم الله الرحمن الرحيم
Altered consciousnessAltered consciousnessand comaand coma
By Dr. Osman Sadig BukhariBy Dr. Osman Sadig Bukhari
The reticular activating The reticular activating substance influence the state of substance influence the state of arousal. Our state of arousal. Our state of consciousness is the product consciousness is the product of complex of complex interactions between parts of interactions between parts of reticular formation itself, cortex reticular formation itself, cortex and brainstem and sensoryand brainstem and sensory
stimuli reaching themstimuli reaching them..
ComaComa :- :- is a state in which za pt is is a state in which za pt is unrousable and unresponsiveunrousable and unresponsive
to external stimuli to external stimuli
- - Glasgow Coma ScaleGlasgow Coma Scale (GCS) is (GCS) is
used for grading comaused for grading coma..
- - It has It has many causesmany causes which should which should
be investigated and treatedbe investigated and treated
- - Diagnostic workup of comatosedDiagnostic workup of comatosed
pt. must proceed concomitantlypt. must proceed concomitantly
with managementwith management..
Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS) Eye openingEye opening (E) (E)::
Spontaneous 4Spontaneous 4 To speech 3To speech 3 To pain 2To pain 2
No response 1No response 1 Motor responseMotor response (M) (M) Obeys 6Obeys 6 localizes 5localizes 5 Withdraws 4Withdraws 4 flexion 3flexion 3 Extension 2Extension 2 No response 1No response 1
Verbal responseVerbal response (V) (V) Oriented 5Oriented 5
Confused conversation 4Confused conversation 4
Inappropriate words 3Inappropriate words 3
Incomprehensive sounds 2Incomprehensive sounds 2
No response 1No response 1
GCS= E+M+VGCS= E+M+V
- - 50%50% of pts wz score of 4 or less will dieof pts wz score of 4 or less will die
- - Death is rare wz score of 13 or moreDeath is rare wz score of 13 or more
- -GCS should be assessed every ½-2 hrsGCS should be assessed every ½-2 hrs..
Mechanism of comaMechanism of coma:: 11 - -diffuse brain dysfndiffuse brain dysfn as in metabolic and as in metabolic and
toxic disorders which depress brain fntoxic disorders which depress brain fn..
22 - -lesions within za brainstemlesions within za brainstem which which
damage za reticular activating systemdamage za reticular activating system
33 - -pressure effect on za brainstempressure effect on za brainstem from from
mass lesions inhibiting za reticularmass lesions inhibiting za reticular
activating systemactivating system
Causes of comaCauses of coma:: 11 - -Head injuryHead injury ( extradural hage, SDH and ( extradural hage, SDH and
cerebral contusioncerebral contusion)) 22 - -InfectionsInfections: - cerebral malaria: - cerebral malaria
- - meningitismeningitis - - encephalitis, African trypanencephalitis, African trypan
33 - -EndocrineEndocrine:- diabetes M:- hypoglycemia:- diabetes M:- hypoglycemia - - DKADKA
- - hyper osmolarhyper osmolar - - hypothyroidismhypothyroidism - - hypopituitarismhypopituitarism - - hypoadrenalismhypoadrenalism..
44 - -Metabolic:-Metabolic:- hypo & hyper natraemia hypo & hyper natraemia - - hypo & hyper calcemiahypo & hyper calcemia..
- - metabolic acidosismetabolic acidosis - - renal, hepatic & resp failurerenal, hepatic & resp failure
- - porphyriaporphyria - - thiamine deficiencythiamine deficiency..
55 - -Toxins & drug overdoseToxins & drug overdose-:-: - - alcoholalcohol
- - CO poisoningCO poisoning - - barbiturates, etcbarbiturates, etc..
66 - -EpilepsyEpilepsy 77 - -Cerebrovascular diseasesCerebrovascular diseases..
88 - -Heat stroke, hypothermia, hypoxiaHeat stroke, hypothermia, hypoxia
99 - -Intracranial mass lesionsIntracranial mass lesions
1010 - -PsychogenicPsychogenic
Immediate assessment andImmediate assessment and
Emergency measuresEmergency measures::
11 - -Position:Position: pt on one side wz za neck pt on one side wz za neck
partly extendedpartly extended..
22 - -Ensure Ensure AAirwayirway, B, Breathingreathing & C & Circulationirculation
55 - -Dextrose 50%Dextrose 50%
66 - -Head injuryHead injury: observe & investigate: observe & investigate
77 - -Spinal injurySpinal injury: immobilize: immobilize..
88 - -Take blood forTake blood for sugar, electrolytes, Ca sugar, electrolytes, Ca
renal & hepatic fn, blood gases, toxicolrenal & hepatic fn, blood gases, toxicol
99 - -Document degree of coma using GCSDocument degree of coma using GCS
Further steps to identify za causeFurther steps to identify za cause:: 11 - -HistoryHistory taken from a relative, eye wittn taken from a relative, eye wittn
or policemanor policeman - - Look for Look for identification card, wrist bandidentification card, wrist band
or necklaceor necklace e.g. diabetics, epileptics e.g. diabetics, epileptics and pts on C/Sand pts on C/S..
- - Onset Onset of coma & of coma & time coursetime course of of subsequent eventssubsequent events..
- - History History head injuryhead injury & subsequent & subsequent coursecourse..
- - History of History of feverfever..
- - PMHPMH: DM, epilepsy, renal, hepatic and: DM, epilepsy, renal, hepatic and endocrine dis, psychiatric illnessendocrine dis, psychiatric illness
- - Social & drug historySocial & drug history: insulin, oral hypo: insulin, oral hypo 22 - -General medical examGeneral medical exam in comatosed pt in comatosed pt::
- - Evidence of Evidence of social declinesocial decline - - Evidence of Evidence of traumatrauma
- - TemperatureTemperature - - SSkin & mucous membraneskin & mucous membranes e.g. pallor e.g. pallor
jaundice, cyanosis, purpura, injectionjaundice, cyanosis, purpura, injection marks, sweats, texture (dry & coarsemarks, sweats, texture (dry & coarse
in hypothyr), rash, pigmentationin hypothyr), rash, pigmentation..
- - BBreathreath: for alcohol, acetone, hepatic: for alcohol, acetone, hepatic and uraemic fetorand uraemic fetor . .
- - RRespirationespiration:- :- KussmaulKussmaul breathing breathing.. - - Chyne StokesChyne Stokes breathing breathing
- - Central neurogenicCentral neurogenic hypervent in pontine lesihypervent in pontine lesi
( ( deep & rapid breathingdeep & rapid breathing)) - - ataxic respataxic resp: shallow, halt: shallow, halt irregular resp. wz medullirregular resp. wz medull
resp centre damage & resp centre damage & usually preceeds death usually preceeds death
- - GGeneral systemic exameneral systemic exam.. 33 - -Neurological exam in comatosed ptNeurological exam in comatosed pt::
a- Ha- Head, neck & spineead, neck & spine b- Pupil size & reaction to lightb- Pupil size & reaction to light
- - unilateral light fixed dilated pupil= unilateral light fixed dilated pupil= coning of za uncus (compress of 3) coning of za uncus (compress of 3)
- - bilateral light fixed dilatedbilateral light fixed dilated pupil= brain stem death, deeppupil= brain stem death, deep
coma from barbit, hypothcoma from barbit, hypoth.. - - unilat. small pupil + ptosis= Hornersunilat. small pupil + ptosis= Horners
- - bilateral pin point light fixed pupilsbilateral pin point light fixed pupils = = pontine hage, opiate poisoningpontine hage, opiate poisoning
- - bilateral mid point reactive pupils=metabbilateral mid point reactive pupils=metab and CNS depressants except opiatand CNS depressants except opiat
c- c- Ocular movementsOcular movements - - sustained conjugate lateral deviationsustained conjugate lateral deviation
occurs towards za side of a destructiveoccurs towards za side of a destructive frontal lesionfrontal lesion
- - dysconjugate deviation= structural dysconjugate deviation= structural brainstem lesion brainstem lesion
- - oculocephalic response (dolls head reflxoculocephalic response (dolls head reflx is lost in deep coma & BDis lost in deep coma & BD
- - caloric or vestibulo-ocular reflex is lostcaloric or vestibulo-ocular reflex is lost in coma due to BDin coma due to BD . .
- - skew deviation= brain stem or cerebellskew deviation= brain stem or cerebell lesionslesions..
- - ocular bobbing= pontine or cerebell lesocular bobbing= pontine or cerebell les d-d- Fundi: Fundi: for papilloedema & haemorrhage for papilloedema & haemorrhage
e- e- Lateralizing signsLateralizing signs - - facial asymmetryfacial asymmetry
- - tonetone - - asymmetric response to painful stimulasymmetric response to painful stimul
- - asymmetry of planter responseasymmetry of planter response - - asymmetry of reflexesasymmetry of reflexes
- - asymmetry of decorticate orasymmetry of decorticate or decerebrate posturingdecerebrate posturing..
Investigation of comatosed ptInvestigation of comatosed pt - - BFM - Urine ex. - CBCBFM - Urine ex. - CBC
- - blood biochemstryblood biochemstry
- - Endocrine - ToxicologyEndocrine - Toxicology
- - ECG & CXRECG & CXR
- - immaging - EEG - ABGimmaging - EEG - ABG
- - CSF - blood cultureCSF - blood culture
Management of comatosed ptManagement of comatosed pt 11 - -careful nursingcareful nursing
22 - -attention to attention to AAirway, irway, BBreathing & reathing & CCirculircul 33 - -IV canulae & fluidsIV canulae & fluids
44 - -NG tube & feeding (calories)NG tube & feeding (calories) 55 - -catheterizationcatheterization
66 - -frequent monitoring & charting offrequent monitoring & charting of vital signsvital signs..
77 - -skin care & oral hygieneskin care & oral hygiene 88 - -care of za eyecare of za eye
99 - -treat za treat za CAUSECAUSE..
Brain death (BD)Brain death (BD) - - Death= no spontaneous resp or heartDeath= no spontaneous resp or heart
beatbeat..
- - BD should be considered in deeplyBD should be considered in deeply
comatosed ventilated pts in whomcomatosed ventilated pts in whom
curable causes have been excludedcurable causes have been excluded..
- -Criteria are laid down before pt put offCriteria are laid down before pt put off
ventilator & organs taken for donationventilator & organs taken for donation..
Pre conditions for diagnosis of BDPre conditions for diagnosis of BD 11 - -Patient Patient deeply comatoseddeeply comatosed
22 - -Patient Patient inadequately breathing or hasinadequately breathing or has
ceased breathing & put on mechanicalceased breathing & put on mechanical
ventilatorventilator i.e. NO spont breathing if pt i.e. NO spont breathing if pt put off ventilator long enough (CO2 put off ventilator long enough (CO2 tension 6.7 kp= 50mm Hg)tension 6.7 kp= 50mm Hg)
33 - -NO drugNO drug is responsible for coma is responsible for coma including N/M blocking agents, including N/M blocking agents, sedatives or anticonvulsantssedatives or anticonvulsants..
44 - -NO hypothermiaNO hypothermia (rectal temp >35) (rectal temp >35)
55 - -NO metabolic or endocrine NO metabolic or endocrine cause of cause of coma. No profound abn of plasma E coma. No profound abn of plasma E and acid- base balance or blood and acid- base balance or blood glucose level. 6- Evidence of glucose level. 6- Evidence of irremediable structuralirremediable structural brain damagebrain damage
e.g. head injury intracranial hagee.g. head injury intracranial hage . . 77--The diag should be confirmedThe diag should be confirmed by 2 by 2 experienced Drs: two consultants orexperienced Drs: two consultants or
at least one consultant & senior registrat least one consultant & senior registr and tests of BD repeated in 24 hrsand tests of BD repeated in 24 hrs
before final diagbefore final diag.. * * Diag of BD: stop vent & other life supporDiag of BD: stop vent & other life suppor
measures. Organ taken for trnasplmeasures. Organ taken for trnaspl . .
Confirmatory tests for BDConfirmatory tests for BD All brain stem reflexes are absentAll brain stem reflexes are absent..
TestsTests: NOT: NOT performed in the presence of seizure or abnormal performed in the presence of seizure or abnormal
posture. Seizures & rigidity are not consistent with BDposture. Seizures & rigidity are not consistent with BD..
11 - -light fixed pupilslight fixed pupils (usually dilated) (usually dilated) 22 - -no gag or cough reflexno gag or cough reflex (oropharyngeal) (oropharyngeal)
33 - -absent corneal reflexesabsent corneal reflexes.. 44 - -absent vestibulo ocular reflexabsent vestibulo ocular reflex 55 - -absent oculocephalic reflexesabsent oculocephalic reflexes
66 - -no motor response within cranial nerveno motor response within cranial nerve territory to painful stimuli. Spinal territory to painful stimuli. Spinal reflexes may be present . 7- reflexes may be present . 7- no resp effort when pt off ventilatorno resp effort when pt off ventilator..
77 - -EEG is not pre requisite for diag of BDEEG is not pre requisite for diag of BD
88 - -Neurological or neurosurgical opinion Neurological or neurosurgical opinion when the primary cause of BD iswhen the primary cause of BD is in in doubtdoubt..