Unconsciousness
description
Transcript of Unconsciousness
Un Un (consciousness)(consciousness)
Dr Antony ThomasDr Antony ThomasConsultant NeurologistConsultant Neurologist
UHCWUHCWAlexandra Hospital Alexandra Hospital
RedditchRedditch
Neural basis of Neural basis of consciousnessconsciousness
ConsciousnessConsciousness cannot be cannot be readily defined in terms of readily defined in terms of anything elseanything else
A state of awareness of A state of awareness of selfself and and surroundingsurrounding
Mental StatusMental Status = =
Arousal + ContentArousal + Content
Anatomy of Mental Status Anatomy of Mental Status
Ascending reticular activating system Ascending reticular activating system (ARAS)(ARAS) Activating systems of upper brainstem, Activating systems of upper brainstem,
hypothalamus, thalamushypothalamus, thalamus Determines the level of Determines the level of arousalarousal
Cerebral hemispheres and interaction Cerebral hemispheres and interaction between functional areas in cerebral between functional areas in cerebral hemisphereshemispheres Determines the Determines the intellectual and emotionalintellectual and emotional
functioningfunctioning
Interaction betweenInteraction between cerebral cerebral hemispheres and activating systemshemispheres and activating systems
Sum of patient’s Sum of patient’s intellectualintellectual (cognitive) functions and (cognitive) functions and emotionsemotions (affect)(affect)
Sensations, emotions, memories, Sensations, emotions, memories, images, ideas (SEMII)images, ideas (SEMII)
Depends upon the activities of the Depends upon the activities of the cerebral cortexcerebral cortex, the , the thalamusthalamus & their & their interrelationship interrelationship
The content of consciousness
Lesions of these structures will diminish the content of consciousness (without changing the state of consciousness)
The The ascending RASascending RAS, from the lower , from the lower border of the border of the ponspons to the to the ventromedial ventromedial thalamusthalamus
The cells of origin of this system The cells of origin of this system occupy a occupy a paramedian area in the paramedian area in the brainstem brainstem
The state of consciousness (arousal)
Abnormal change in level of Abnormal change in level of arousalarousal or altered or altered content content of a patient's thought processesof a patient's thought processes
Change in the level of arousal or Change in the level of arousal or
alertnessalertness inattentiveness, lethargy, stupor, and coma.inattentiveness, lethargy, stupor, and coma.
Change in contentChange in content ““Relatively Relatively simplesimple” changes: e.g. ” changes: e.g. speech, speech,
calculations, spellingcalculations, spelling More More complexcomplex changes: changes: emotions, behavior or emotions, behavior or
personalitypersonality Examples: Examples: confusionconfusion, , disorientationdisorientation, , hallucinationshallucinations, ,
poor comprehensionpoor comprehension, or , or verbal expressive difficultyverbal expressive difficulty
Altered Mental Status
Definitions of levels of arousal Definitions of levels of arousal (conciousness)(conciousness)
Alert Alert (Conscious)(Conscious) - - Appearance of wakefulness, Appearance of wakefulness, awareness of the self and environment awareness of the self and environment
Lethargy Lethargy -- mildmild reduction in alertness reduction in alertness
ObtundationObtundation -- moderatemoderate reduction in alertness. reduction in alertness. Increased Increased response timeresponse time to stimuli. to stimuli.
StuporStupor - - Deep sleep, patient can be aroused only by Deep sleep, patient can be aroused only by vigorous and repetitivevigorous and repetitive stimulation. Returns to deep stimulation. Returns to deep sleep when not continually stimulatedsleep when not continually stimulated..
Coma (Unconscious)Coma (Unconscious) - - Sleep likeSleep like appearance and appearance and behaviorally behaviorally unresponsiveunresponsive to all external stimuli to all external stimuli ((UnarousableUnarousable unresponsivenessunresponsiveness, , eyes closedeyes closed) )
Psychogenic Psychogenic unresponsivenessunresponsiveness
The patient, although apparently The patient, although apparently unconscious, usually shows unconscious, usually shows some some response to external stimuliresponse to external stimuli
An attempt to elicit the An attempt to elicit the corneal reflexcorneal reflex may cause a vigorous contraction of may cause a vigorous contraction of the orbicularis oculithe orbicularis oculi
Marked Marked resistance to passive resistance to passive movementmovement of the limbs may be of the limbs may be present, and signs of organic disease present, and signs of organic disease are absent are absent
Locked in syndromeLocked in syndrome
Patient is Patient is awake and alertawake and alert, but , but unable unable to move or speak. to move or speak.
Pontine lesionsPontine lesions affect lateral eye affect lateral eye movement and motor controlmovement and motor control
Lesions often Lesions often sparespare vertical eye vertical eye movementsmovements and and blinking.blinking.
Vegetative
Locked-in
Confusional stateConfusional state
Major defectMajor defect: lack of attention: lack of attention DisorientationDisorientation to time > place > to time > place >
personperson Patient thinks Patient thinks less clearlyless clearly and and more more
slowlyslowly MemoryMemory faulty (difficulty in repeating faulty (difficulty in repeating
numbers (digit span)numbers (digit span) MisinterpretationMisinterpretation of external stimuli of external stimuli Drowsiness may Drowsiness may alternatealternate with hyper - with hyper -
excitability and irritability excitability and irritability
DeliriumDelirium
Markedly abnormal mental Markedly abnormal mental statestate Severe confusional stateSevere confusional state PLUSPLUS Visual hallucinations &/or Visual hallucinations &/or
delusionsdelusions(complex systematized dream like (complex systematized dream like state) state)
Marked: Marked: disorientation,disorientation, fear, irritability, fear, irritability, misperception of sensory stimulimisperception of sensory stimuli
Pt. Pt. out of true contactout of true contact with environment with environment and other people and other people
Common causesCommon causes: : 1.1. ToxinsToxins2.2. metabolic metabolic disordersdisorders3.3. partial complex partial complex seizuresseizures4.4. head head traumatrauma5.5. acute febrile systemic illnesses acute febrile systemic illnesses
To cause comaTo cause coma, , as defined as a as defined as a state of state of unconsciousnessunconsciousness in which in which the the eyes are closedeyes are closed and and sleep–sleep–wake cycles absentwake cycles absent
Lesion of the cerebral Lesion of the cerebral hemisphereshemispheres extensive and extensive and bilateralbilateral
Lesions of the Lesions of the brainstembrainstem: : above above the lower 1/3 of the ponsthe lower 1/3 of the pons and and destroy destroy both sides of the both sides of the paramedianparamedian reticulum reticulum
The use of The use of terms other than terms other than coma and stuporcoma and stupor to indicate the to indicate the degree of impairment of degree of impairment of consciousness is beset with consciousness is beset with difficulties and more important difficulties and more important is the use of coma scales is the use of coma scales ((Glasgow Coma ScaleGlasgow Coma Scale))
Glasgow Coma Scale (GCS)Glasgow Coma Scale (GCS)Best eye Best eye
response (E) response (E) Best verbal Best verbal
response (V) response (V) Best motor Best motor
response (M)response (M)
4 4 Eyes opening Eyes opening
spontaneouslyspontaneously 5 5 Oriented Oriented 6 6 Obeys commandsObeys commands
3 3 Eye opening to Eye opening to
speechspeech 4 4 ConfusedConfused 5 5 Localizes to painLocalizes to pain
2 2 Eye opening in Eye opening in response to painresponse to pain
3 3 Inappropriate Inappropriate
wordswords 4 4 Withdraws from Withdraws from
painpain
1 1 No eye opening No eye opening 2 2 Incomprehensible Incomprehensible
soundssounds 3 3 Flexion in response Flexion in response
to painto pain
1 1 None None 2 2 Extension to pain Extension to pain
1 1 No motor responseNo motor response
Individual Individual elements as well as elements as well as the sumthe sum of the score are important. of the score are important.
Hence, the score is expressed in the Hence, the score is expressed in the form "form "GCS 9GCS 9 = = EE2 2 VV4 4 MM3 3 at 07:35at 07:35
Generally, comas are classified as:Generally, comas are classified as: SevereSevere, with GCS ≤ 8 , with GCS ≤ 8 ModerateModerate, GCS 9 - 12 , GCS 9 - 12 MinorMinor, GCS ≥ 13. , GCS ≥ 13.
Approaches to DD Approaches to DD
Glucose, ABG, Lytes, Glucose, ABG, Lytes, Mg, Ca, Tox, Mg, Ca, Tox,
ammoniaammonia
Unresponsive
ABCs
IV D50, narcan, flumazenil
CT
Brainstem or other
Focal signs
Diffuse brain dysfunction
metabolic/ infectious
Unconscious
Focal lesions
Tumor, ICH/SAH/ infarction
Pseudo-Coma
Psychogenic, Looked-in,
NM paralysis
LP± CT
Y N
Y
N
Approaches to DD Approaches to DD
General examination:General examination:
On arrival to ER immediate attention to: On arrival to ER immediate attention to:
1.1. AirwayAirway
2.2. CirculationCirculation
3.3. establishing establishing IV accessIV access
4.4. Blood Blood should be withdrawn: should be withdrawn: estimation of estimation of glucoseglucose # # other other biochemicalbiochemical parameters # parameters # drugdrug screening screening
Attention is then directed Attention is then directed towardstowards::
1.1. Assessment of the patientAssessment of the patient
2.2. SeveritySeverity of the coma of the coma
3.3. DiagnosticDiagnostic evaluation evaluation All possible information from:All possible information from:
1.1. RelativesRelatives
2.2. ParamedicsParamedics
3.3. Ambulance personnelAmbulance personnel
4.4. BystandersBystanders
particularly about the particularly about the mode of onsetmode of onset
Previous medical historyPrevious medical history: : 1.1. EpilepsyEpilepsy
2.2. DM, Drug historyDM, Drug history
CluesClues obtained from the patient's obtained from the patient's1.1. ClothingClothing or or
2.2. HandbagHandbag
Careful examination forCareful examination for 1.1. TraumaTrauma requires complete exposure and requires complete exposure and
‘log roll’ to examine the ‘log roll’ to examine the backback
2.2. Needle marks Needle marks
If head trauma is suspectedIf head trauma is suspected, the , the examination must await examination must await adequate adequate stabilization of the neck. stabilization of the neck.
Glasgow Coma ScaleGlasgow Coma Scale:: the the severity severity of comaof coma is essential for subsequent is essential for subsequent management. management.
Following thisFollowing this, particular attention , particular attention should be paid to should be paid to brainstem and brainstem and motormotor function. function.
TemperatureTemperatureHypothermiaHypothermia Hypopituitarism, HypothyroidismHypopituitarism, Hypothyroidism ChlorpromazineChlorpromazine Exposure to low temperature Exposure to low temperature
environments,environments, cold-water cold-water immersionimmersion
Risk of hypothermia in the Risk of hypothermia in the elderly with inadequately heated elderly with inadequately heated rooms, exacerbated by rooms, exacerbated by immobility.immobility.
C/P:C/P: generalized generalized rigidityrigidity and muscle and muscle fasciculationfasciculation but true shivering may but true shivering may be absent. (a low-reading be absent. (a low-reading rectal rectal thermometerthermometer is required). is required).
HypoxiaHypoxia and and hypercarbiahypercarbia are are common. common.
Treatment:Treatment:
1.1. Gradual Gradual warming warming is necessary is necessary
2.2. May require May require peritoneal dialysis with peritoneal dialysis with warmwarm fluids. fluids.
Hyperthermia (febrile Coma)Hyperthermia (febrile Coma)
InfectiveInfective: encephalitis, meningitis: encephalitis, meningitis VascularVascular: pontine, subarachnoid hge: pontine, subarachnoid hge MetabolicMetabolic: thyrotoxic, Addisonian : thyrotoxic, Addisonian
crisiscrisis ToxicToxic: belladonna, salicylate : belladonna, salicylate
poisoningpoisoning SunSun stroke, stroke, heatheat stroke stroke Coma with Coma with 2ry infection2ry infection: UTI, : UTI,
pneumonia, bed sores. pneumonia, bed sores.
Hyperthermia or heat strokeHyperthermia or heat stroke
Loss of thermoregulation dt. prolonged Loss of thermoregulation dt. prolonged exertion in a exertion in a hot environmenthot environment
Initial Initial ↑↑ in body in body temperaturetemperature with with profuse profuse sweatingsweating followed by followed by
hyperpyrexiahyperpyrexia, an abrupt , an abrupt cessation of cessation of sweatingsweating, , and thenand then
rapid onset of comarapid onset of coma, , convulsionsconvulsions, and , and deathdeath
This may be This may be exacerbated by certain exacerbated by certain drugsdrugs, ‘Ecstasy’ abuse—involving a loss , ‘Ecstasy’ abuse—involving a loss of the thirst reaction in individuals of the thirst reaction in individuals engaged in engaged in prolonged dancingprolonged dancing. .
Other causesOther causes TetanusTetanus Pontine hgePontine hge Lesions in the floor of the third Lesions in the floor of the third
ventricleventricle Neuroleptic malignant syndromeNeuroleptic malignant syndrome Malignant hyperpyrexia with Malignant hyperpyrexia with
anaesthetics. anaesthetics.
Heat stroke neurological sequelaeHeat stroke neurological sequelae
Paraparesis.Paraparesis. Cerebellar Cerebellar ataxia.ataxia. DementiaDementia (rare) (rare)
PulsePulse BradycardiaBradycardia: brain tumors, opiates, : brain tumors, opiates,
myxedema.myxedema. TachycardiaTachycardia: hyperthyroidism, : hyperthyroidism,
uremiauremia
Blood PressureBlood Pressure HighHigh: hypertensive encephalopathy: hypertensive encephalopathy LowLow: Addisonian crisis, alcohol, : Addisonian crisis, alcohol,
barbiturate barbiturate
SkinSkin Injuries, BruisesInjuries, Bruises: traumatic causes: traumatic causes Dry SkinDry Skin: DKA, Atropine: DKA, Atropine Moist skinMoist skin: Hypoglycemic coma: Hypoglycemic coma Cherry-redCherry-red: CO poisoning: CO poisoning Needle marksNeedle marks: drug addiction: drug addiction RashesRashes: meningitis, endocarditis : meningitis, endocarditis
PupilsPupils SizeSize, , inequalityinequality, reaction to a bright, reaction to a bright
lightlight. . An important general rule:An important general rule: most most
metabolicmetabolic encephalopathies give encephalopathies give small small pupils with pupils with preserved light preserved light reflex.reflex.
Atropine,Atropine, and and cerebral anoxiacerebral anoxia tend to tend to dilatedilate the pupils, and the pupils, and opiatesopiates will will constrictconstrict them. them.
Structural lesionsStructural lesions are more commonly are more commonly associated with associated with pupillary asymmetrypupillary asymmetry and with and with loss of light reflexloss of light reflex..
Midbrain tectal lesionsMidbrain tectal lesions : round, : round, regular, medium-sized pupils, regular, medium-sized pupils, do not do not reactreact to light to light
Midbrain nuclear lesionsMidbrain nuclear lesions: medium-: medium-sized pupils, sized pupils, fixedfixed to all stimuli to all stimuli, often , often irregular and unequalirregular and unequal..
Cranial n III distal to the nucleusCranial n III distal to the nucleus: : Ipsilateral Ipsilateral fixedfixed, , dilateddilated pupil. pupil.
Pons (Tegmental lesions)Pons (Tegmental lesions) : bilaterally : bilaterally small pupilssmall pupils, {in pontine hge, may be , {in pontine hge, may be pinpointpinpoint, although , although reactivereactive}} assess the assess the light response using a light response using a magnifying glassmagnifying glass
Lateral medullary lesionLateral medullary lesion: : ipsilateral ipsilateral Horner'sHorner's syndrome. syndrome.
Occluded carotid arteryOccluded carotid artery causing causing cerebral infarction: Pupil on that side is cerebral infarction: Pupil on that side is often often small small
Small, reactive
Diencephalons
Dilated, Fixed
small, pinpointIn hge reactive
Pons
Midbrain
Ipsilateral dilated, Fixed
Medium-sized, fixed
.
The oculocephalic (doll's head) The oculocephalic (doll's head) responseresponse
Caloric oculovestibular responsesCaloric oculovestibular responses
Odour of breathOdour of breath
AcetoneAcetone: DKA: DKA Fetor HepaticusFetor Hepaticus: in hepatic coma: in hepatic coma Urineferous odourUrineferous odour: in uremic coma: in uremic coma Alcohol odourAlcohol odour: in alcohol intoxication: in alcohol intoxication
RespirationRespiration Cheyne–Stokes respirationCheyne–Stokes respiration: :
( (hyperpnoeahyperpnoea alternates with alternates with apneasapneas) is commonly found in ) is commonly found in comatose patients, often with comatose patients, often with cerebralcerebral disease, but is relatively disease, but is relatively non-specificnon-specific. .
Rapid, regular respirationRapid, regular respiration is also is also common in comatose patients and is common in comatose patients and is often found with often found with pneumoniapneumonia or or acidosisacidosis. .
Central neurogenic hyperventilationCentral neurogenic hyperventilation
Brainstem tegmentumBrainstem tegmentum ( (mostly mostly tumorstumors)): :
↑ ↑ PO2PO2, , ↓↓ PCO2PCO2, and , and
Respiratory Respiratory alkalosisalkalosis in the in the absence of absence of any evidence of pulmonaryany evidence of pulmonary disease disease
Sometimes complicates Sometimes complicates hepatic hepatic encephalopathyencephalopathy
Apneustic breathingApneustic breathing BrainstemBrainstem lesions lesions PonsPons may also may also
give with a give with a pause at full pause at full inspirationinspiration
Ataxic:Ataxic: Medullary lesions:Medullary lesions: irregular irregular
respirationrespiration with with random deeprandom deep and and shallowshallow breaths breaths
Cheyne-Stocks
Ataxic
Apneustic
Central Neurogenic Hyperventilation
Cluster
Abnormal breathing patterns in Abnormal breathing patterns in comacoma
Midbrain
Pons
Medulla
ARAS
Cheynes - Stokes
Ataxic
Apneustic
Central Neurogenic
Motor functionMotor function Particular attention should be directed Particular attention should be directed
towards asymmetry of towards asymmetry of tone or tone or movementmovement. .
The The plantarplantar responses are usually responses are usually extensor, but asymmetry is again extensor, but asymmetry is again important. important.
The The tendon reflexestendon reflexes are less useful. are less useful. The motor The motor response to painful stimuliresponse to painful stimuli
should be assessed carefully (part of should be assessed carefully (part of GCS) GCS)
Painful stimuliPainful stimuli: supraorbital nerve : supraorbital nerve pressure and nail-bed pressure. pressure and nail-bed pressure. Rubbing of the Rubbing of the sternumsternum should be should be avoidedavoided (bruising and distress to the (bruising and distress to the relatives)relatives)
Patients may localize or exhibit a Patients may localize or exhibit a variety of responses, variety of responses, asymmetryasymmetry is is important important
FlexionFlexion of the of the upperupper limb with limb with extensionextension of the of the lower lower limb limb ((decorticate decorticate responseresponse) and ) and extension of the extension of the upper and lower upper and lower limb limb (decerebrate (decerebrate response) response) indicate a more indicate a more severe severe disturbance and disturbance and prognosis. prognosis.
Signs of lateralizationSigns of lateralization
Unequal Unequal pupilspupils Deviation of the Deviation of the eyeseyes to one side to one side FacialFacial asymmetry asymmetry Turning of the Turning of the headhead to one side to one side Unilateral hypo-hyperUnilateral hypo-hypertoniatonia Asymmetric deep Asymmetric deep reflexesreflexes Unilateral extensor Unilateral extensor plantarplantar response response
(Babinski)(Babinski) Unilateral focal or Jacksonian Unilateral focal or Jacksonian fitsfits
Head and neckHead and neck The headThe head
1.1. Evidence of injury Evidence of injury
2.2. Skull should be palpated for Skull should be palpated for depressed fractures. depressed fractures.
The ears and nose:The ears and nose: haemorrhage haemorrhage and leakage of CSFand leakage of CSF
The fundi:The fundi: papilloedema or papilloedema or subhyaloid or retinal haemorrhages subhyaloid or retinal haemorrhages
NeckNeck: In the presence of trauma to : In the presence of trauma to the head, associated trauma to the the head, associated trauma to the neck should be assumed until neck should be assumed until proven otherwise.proven otherwise.
Positive Positive Kernig's signKernig's sign : a meningitis : a meningitis or SAH. or SAH. If established as safe to do If established as safe to do so, the cervical spine should be so, the cervical spine should be gently flexed gently flexed
Neck stiffnessNeck stiffness may occur: may occur:
1.1. ↑ ↑ ICPICP
2.2. incipient tonsillar herniation incipient tonsillar herniation
Causes of Causes of COMACOMA
Cerebrovascular disease is a frequent Cerebrovascular disease is a frequent cause of coma. cause of coma.
Mechanism:Mechanism:
Impairment of perfusion of the RAS Impairment of perfusion of the RAS With With hypotensionhypotension Brainstem herniationBrainstem herniation ( parenchymal ( parenchymal
hge, swelling from infarct, or more hge, swelling from infarct, or more rarely, extensive brainstem infarction)rarely, extensive brainstem infarction)
CNS causes of coma
Loss of consciousness is commonLoss of consciousness is common with SAH with SAH
only about 1/2 of patients only about 1/2 of patients recover from the initial effects of recover from the initial effects of the haemorrhage. the haemorrhage.
Causes of comaCauses of coma: :
1.1. Acute ↑Acute ↑ICPICP and and
2.2. Later, Later, vasospasmsvasospasms, , hyponatraemiahyponatraemia
Subarachnoid haemorrhage
May cause a rapid decline in May cause a rapid decline in consciousness, from consciousness, from
1.1. Rupture into the ventriclesRupture into the ventricles
2.2. or subsequent or subsequent herniationherniation and and brainstem compression. brainstem compression.
Cerebellar haemorrhage or infarctCerebellar haemorrhage or infarct with with
1.1. Subsequent Subsequent oedemaoedema
2.2. Direct brainstem compressionDirect brainstem compression, early , early decompression can be lifesaving. decompression can be lifesaving.
Parenchymal haemorrhage
The critical blood flow in humans The critical blood flow in humans required to maintain effective required to maintain effective cerebral activity is about cerebral activity is about 20 20 ml/100 g/minml/100 g/min and and any fall below any fall below this leads rapidly to cerebral this leads rapidly to cerebral insufficiency. insufficiency.
The causes: The causes:
1.1. syncopesyncope in in youngeryounger patients patients
2.2. cardiaccardiac disease in disease in older older patients. patients.
Hypotension
Now Now rare with better control of rare with better control of blood pressure. blood pressure.
C/PC/P: impaired consciousness, : impaired consciousness, grossly raised blood pressure, grossly raised blood pressure, papilloedema. papilloedema.
Neuropathologically: Neuropathologically: fibrinoid fibrinoid necrosis, arteriolar thrombosis, necrosis, arteriolar thrombosis, microinfarction, and cerebral microinfarction, and cerebral oedemaoedema (failure of autoregulation) (failure of autoregulation)
Hypertensive encephalopathy
Mass effectsMass effects: tumours, abscesses, : tumours, abscesses, haemorrhage, subdural, haemorrhage, subdural, extradural haematoma, brainstem extradural haematoma, brainstem herniation→ distortion of the RAS.herniation→ distortion of the RAS.
C/PC/P: depends on normal variation : depends on normal variation in the tentorial aperture, site of in the tentorial aperture, site of lesion, and the speed of lesion, and the speed of development. development.
Raised intracranial pressure
Herniation and loss of consciousness Herniation and loss of consciousness Lesions located deeply, laterally, or in Lesions located deeply, laterally, or in the temporal lobes > located at a the temporal lobes > located at a distance, such as the frontal and distance, such as the frontal and occipital lobes. occipital lobes.
Rate of growth: Rate of growth: slowly growing slowly growing tumours may achieve a substantial tumours may achieve a substantial size and distortion of cerebral size and distortion of cerebral structure without impairment of structure without impairment of consciousness, in contrast to small consciousness, in contrast to small rapidly expanding lesions rapidly expanding lesions
Central herniationCentral herniation involves involves downward displacement of the downward displacement of the upper brainstemupper brainstem
Uncal herniationUncal herniation in which the in which the medial temporal lobe herniates medial temporal lobe herniates through the tentorium through the tentorium
The leading cause of The leading cause of deathdeath below the below the age of 45, head injury accounts for age of 45, head injury accounts for 1/2 of all trauma deaths 1/2 of all trauma deaths
A major causeA major cause of patients presenting of patients presenting with with comacoma. .
A A historyhistory is usually available and, if is usually available and, if not, not, signs of injurysigns of injury such as bruising of such as bruising of the scalp or skull fracture lead one to the scalp or skull fracture lead one to the diagnosis the diagnosis
Head injury
Other Neurological causesOther Neurological causes
InfectionsInfections Epileptic SeizuresEpileptic Seizures Raised ICP ( Posterior Fossa tumours, Raised ICP ( Posterior Fossa tumours,
hydrocephalus)hydrocephalus) Sleep disordersSleep disorders StrokeStroke Basilar Artery MigraineBasilar Artery Migraine
OthersOthers
Cardiac arrhythmiaCardiac arrhythmia HOCMHOCM PEPE ASAS
Metabolic causes of comaMetabolic causes of coma
Hepatic ComaHepatic Coma
Renal ComaRenal Coma
DKADKA
HONKHONK
Hypglycaemic ComaHypglycaemic Coma
Pituitary FailurePituitary Failure Pituitary ApoplexyPituitary Apoplexy Myxedema ComaMyxedema Coma HyperthyroidismHyperthyroidism Adrenocortical FailureAdrenocortical Failure
Other endocrine causes of coma
Hypo & Hyper CaHypo & Hyper Ca
Hypo & Hyper MgHypo & Hyper Mg
Ca, Mg metabolism
SeizuresSeizures
Definition:- Definition:- A seizure is the clinical event that result from A seizure is the clinical event that result from
abnormal excessive neuronal activity. abnormal excessive neuronal activity. Etiology:- Etiology:- --Alteration of consciousness, motor activity, behavior, Alteration of consciousness, motor activity, behavior,
sensation or autonomic function.sensation or autonomic function.-It may be viewed as a symptom of an underlying disease -It may be viewed as a symptom of an underlying disease
process.process.
Classification:-Classification:- Acute non recurrent convulsionsAcute non recurrent convulsions:-:-One or more convulsive fits that occur during the same One or more convulsive fits that occur during the same
acute illness & do not recur after recovery:-acute illness & do not recur after recovery:- Febrile convulsions. – hypertensive Febrile convulsions. – hypertensive
encephalopathy.encephalopathy. CNs infections:- meningitis, encephalitis.CNs infections:- meningitis, encephalitis. Intra cranial Hemorrhage: spontaneous, or Intra cranial Hemorrhage: spontaneous, or
traumatic traumatic Toxic:- e.g tetanus. – Intracranial tumors.Toxic:- e.g tetanus. – Intracranial tumors. Anoxic:- sudden severe asphyxia.Anoxic:- sudden severe asphyxia. Metabolic:- hypoglycemia, hypocalcaemia, hypo Metabolic:- hypoglycemia, hypocalcaemia, hypo
or hypernateremia.or hypernateremia.
Chronic recurrent convulsions:-Chronic recurrent convulsions:-Recurrent attacks of convulsions with symptoms Recurrent attacks of convulsions with symptoms
free intervals:-free intervals:-
*Epilepsy:*Epilepsy:
-- Idiopathic. -- Idiopathic.
--Neurocutaneous synd. Such as Sturge---Neurocutaneous synd. Such as Sturge-weber, neurofibromatosis, tuberous weber, neurofibromatosis, tuberous scelosis.scelosis.
Organic secondary to brain insult:- post- Organic secondary to brain insult:- post- infection, post- traumatic, post- hypoxic, infection, post- traumatic, post- hypoxic, post- toxic.post- toxic.
Benign neonatal convulsions. Benign neonatal convulsions.
*Degenerative*Degenerative brain disease. brain disease.
*Congenital cerebral malformation.*Congenital cerebral malformation.
Electrical rhythm in epilepsyElectrical rhythm in epilepsy
EpilepsyEpilepsyDefined as Increased Neuronal Defined as Increased Neuronal
ExcitabilityExcitability
PartialPartial:- Epileptic focus start :- Epileptic focus start localized and remain localized: localized and remain localized:
Classified according to level of consciousness:Classified according to level of consciousness: No loss of consciousness:No loss of consciousness: Motor – Sensory – Autonomic.Motor – Sensory – Autonomic. Loss of Consciousness: Temporal lobe epilepsy.Loss of Consciousness: Temporal lobe epilepsy.
GeneralizedGeneralized:- :- Epileptic focus start Epileptic focus start localized then become generalizedlocalized then become generalized..
Grandmal – Febrile - Status epilepticus – Grandmal – Febrile - Status epilepticus – Myoclonic Myoclonic
Clonic – Atonic.-- Petite mal (typical and atypical) Clonic – Atonic.-- Petite mal (typical and atypical) – Tonic.– Tonic.
Unclassified Unclassified
Generalized tonic clonicGeneralized tonic clonic
(grand-mal epilepsy)(grand-mal epilepsy)The commonest form of childhood convulsions The commonest form of childhood convulsions
60%:-60%:-
-An aura:--An aura:- unusual behaviors recognized by the unusual behaviors recognized by the mother. mother.
-Tonic phase:--Tonic phase:- powerful sustained contraction(5 powerful sustained contraction(5 minutes):-minutes):-
The patient falls to the ground stiff due to The patient falls to the ground stiff due to powerful sustained contraction of all powerful sustained contraction of all muscles.muscles.
Arm flexed - Legs extended.Arm flexed - Legs extended.
-Clonic phase:--Clonic phase:- Rhythmical contraction and Rhythmical contraction and relaxation of muscles of limbs and face:- Biting relaxation of muscles of limbs and face:- Biting the tongue and incontinence may occur during the tongue and incontinence may occur during the clonic phase.the clonic phase.
-Duration of attack is variable but if exceed 20 -Duration of attack is variable but if exceed 20 minutes it considered status epilepticus.minutes it considered status epilepticus.
-Post epileptic phase-Post epileptic phase:- The child falls in :- The child falls in deep sleep and afterwards he may be deep sleep and afterwards he may be confused or irritable.confused or irritable.
Grand-mal epilepsy has good prognosis if Grand-mal epilepsy has good prognosis if the first attack start after the age of the first attack start after the age of 3years and the mental development is 3years and the mental development is normal.normal.
Febrile convulsionFebrile convulsionDefinition:- Definition:- Generalized tonic clonic Generalized tonic clonic
convulsions which occasionally occur at convulsions which occasionally occur at the onset of acute extra-cranial infections.the onset of acute extra-cranial infections.
Incidence:-Incidence:- 3-5% in all children.3-5% in all children.
Etiology:-Etiology:- At the onset of acute extra-cranial infections At the onset of acute extra-cranial infections
such as tonsillitis.such as tonsillitis.- Febrile seizures may signify a serious - Febrile seizures may signify a serious
underlying acute infections.underlying acute infections.- In association with high environmental - In association with high environmental
temp.temp.Clinical picture:-Clinical picture:- Criteria for diagnosis of simple febrile convulsions:- Criteria for diagnosis of simple febrile convulsions:-
Patient type:- Patient type:- Age: 6month to Age: 6month to 6years. - Sex: male more than 6years. - Sex: male more than female. female.
Family history: Family history: Strong positive. Strong positive. - Neurologically & metabolically - Neurologically & metabolically
free.free.
Seizures stages:-Seizures stages:- PrePre- Ictal:- Convulsions occur at the - Ictal:- Convulsions occur at the
onset of temperature 39onset of temperature 39oo c or more. c or more. IctalIctal:- Generalized tonic clonic.:- Generalized tonic clonic. Short duration:- 5-15 minutes.Short duration:- 5-15 minutes. Course:- Usually one convulsive fit Course:- Usually one convulsive fit
during the same illness.during the same illness. Post-Post-ictal:- Short postictal stupor.ictal:- Short postictal stupor.
InvestigationInvestigation Laboratory:-Laboratory:-CSF analysisCSF analysis: Indicated if any doubt : Indicated if any doubt
exist regarding the possibility of exist regarding the possibility of meningitis.meningitis.
EEG:- EEG:- Indicated in Indicated in atypicalatypical febrile seizure febrile seizure persists persists for more than 15 minutes or recurrent for more than 15 minutes or recurrent more more than 3 time/daythan 3 time/day, or focal seizures., or focal seizures.
A child at risk for developing A child at risk for developing epilepsy:-epilepsy:-
Positive family history of epilepsy Positive family history of epilepsy Initial febrile seizures before the age of 6 Initial febrile seizures before the age of 6
months. months. A febrile seizure.A febrile seizure. Delayed developmental milestone.Delayed developmental milestone. Associated Respiratory manifestation Associated Respiratory manifestation
(cyanosis).(cyanosis).
Prognosis:-Prognosis:- Risk for developing epilepsy Risk for developing epilepsy is 1% in children without risk factors,9% is 1% in children without risk factors,9% with risk factors.with risk factors.
Treatment:-Treatment:- Immediate first aid measures.Immediate first aid measures. Measures to lower the temperature:- Measures to lower the temperature:-
Cold fomentation / Antipyretics. Cold fomentation / Antipyretics. Treatment of the cause of fever e.g Treatment of the cause of fever e.g
Antibiotics for acute tonsillitis.Antibiotics for acute tonsillitis. Short acting anticonvulsant:- Short acting anticonvulsant:-
Diazepam (valium) 0.25mg/kg/dose.Diazepam (valium) 0.25mg/kg/dose.
Generalized absence = petit-mal Generalized absence = petit-mal epilepsyepilepsy
- The commonest age 5-9 years.- The commonest age 5-9 years.- Rare below 2years and never continue after - Rare below 2years and never continue after
15 years.15 years.- Short sudden loss of consciousness.- Short sudden loss of consciousness.- The child suddenly stops talking and stares - The child suddenly stops talking and stares
for few seconds.for few seconds.- Recovery is immediate and child resumes - Recovery is immediate and child resumes
talking.talking.- Not associated with limb movement.- Not associated with limb movement.- Recurrent up to more than 100 times/day.- Recurrent up to more than 100 times/day.- May affect school performance. May affect school performance.
Myoclonic epilepsyMyoclonic epilepsy- Occurs at any age but is more seen in infants and - Occurs at any age but is more seen in infants and
young children.young children.
- Usually associated with mental retardation.- Usually associated with mental retardation.
-The attack which is very frequent, present with -The attack which is very frequent, present with sudden symmetrical mass jerking involving all sudden symmetrical mass jerking involving all limbs.limbs.
Juvenile myoclonic epilepsyJuvenile myoclonic epilepsy-Occurs during adolescence -Occurs during adolescence
––A.D. -Chromosome No. 6A.D. -Chromosome No. 6
––The hallmark is morning myoclonus within 90 The hallmark is morning myoclonus within 90 minutes after awakening.minutes after awakening.
-Resolved with Valporic acid therapy for life.-Resolved with Valporic acid therapy for life.
Atonic (a kinetic) epilepsyAtonic (a kinetic) epilepsy- It is a type of myoclonic epilepsy.- It is a type of myoclonic epilepsy.
- Transient loss of consciousness and falling on the - Transient loss of consciousness and falling on the ground.ground.
- Then immediately the child gets up and resumes - Then immediately the child gets up and resumes activity.activity.
- The condition may be confused with petit mal.The condition may be confused with petit mal.
Benign neonatal convulsionsBenign neonatal convulsions-A.D. - Chromosome No. 20-A.D. - Chromosome No. 20
-Generalized clonic seizures -Generalized clonic seizures
-Occurs toward the end of the 1-Occurs toward the end of the 1stst week of life. week of life.
-Called familial 5-Called familial 5thth day fits. day fits.
-Favorable prognosis.-Favorable prognosis.
Infantile spasm ( West syndrome)Infantile spasm ( West syndrome)
Brief convulsionBrief convulsion of the neck, trunk and arm muscles of the neck, trunk and arm muscles followed byfollowed by sustained muscle contraction lasting 2 to 10 sustained muscle contraction lasting 2 to 10 seconds.seconds.
Occurs when the child awakening or going to sleep.Occurs when the child awakening or going to sleep. Each jerk is followed by a brief period of relaxation, many Each jerk is followed by a brief period of relaxation, many
clusters occurs each day.clusters occurs each day.
EEG EEG showed Hypsarrhythmia ( high- voltage slow waves, showed Hypsarrhythmia ( high- voltage slow waves, spikes and polyspikes).spikes and polyspikes).
Peak age 3-8 months. - It could be mistaken for infantile Peak age 3-8 months. - It could be mistaken for infantile colic.colic.
TreatmentTreatment by ACTH,or oral steroids, or benzodiazepines,or by ACTH,or oral steroids, or benzodiazepines,or valproic acid and vigabatrinis also promising.valproic acid and vigabatrinis also promising.
Status epilepticusStatus epilepticusDefinition:- Definition:- Continuous convulsion or repeated Continuous convulsion or repeated
convulsions without return of the level of convulsions without return of the level of consciousness more than 20 min.consciousness more than 20 min.
Causes:- Causes:- -Sudden withdrawal of anticonvulsant. -Sudden withdrawal of anticonvulsant. --Febrile Febrile convulsion in poorly controlled convulsion in poorly controlled
epileptic patient. epileptic patient. --Metabolic or toxic.Metabolic or toxic.
Management:Management:1-Stop the convulsion by:-1-Stop the convulsion by:-
- Diazepam 0.2 – 0.4mg / kg / dose I.V. or - Diazepam 0.2 – 0.4mg / kg / dose I.V. or 0.5mg/kg/dose rectally.0.5mg/kg/dose rectally.
- Chloral hydrate or paraldehyde:- 0.15 mg/kg - Chloral hydrate or paraldehyde:- 0.15 mg/kg diluted in saline I.V or 0.5ml/kg/dose rectallydiluted in saline I.V or 0.5ml/kg/dose rectally
- If failed give general anesthesia (short acting - If failed give general anesthesia (short acting barbiturates).barbiturates).
2-Long-term anticonvulsant:- 2-Long-term anticonvulsant:- Phenobarbitone 3-5mg/kg/day.Phenobarbitone 3-5mg/kg/day. Diphenylhydantoin 5-8mg/kg/day.Diphenylhydantoin 5-8mg/kg/day.
3-Evaluation of the patient: 3-Evaluation of the patient: After the After the attack Todd's paralysis may occur and then attack Todd's paralysis may occur and then resolve completely.resolve completely.
Partial (focal) seizuresPartial (focal) seizures Motor : Motor : Jacksonian epilepsyJacksonian epilepsy (simple partial motor seizures):-(simple partial motor seizures):-
Involve the motor area of the brain and the Involve the motor area of the brain and the patient is alert.patient is alert.
Consists of clonic movements in a localized Consists of clonic movements in a localized group of muscles. Commonly at the Corner group of muscles. Commonly at the Corner of mouth, Thumb, and Great toe. of mouth, Thumb, and Great toe.
Jacksonian march:- The neuronal discharge Jacksonian march:- The neuronal discharge may spread to other parts on the same may spread to other parts on the same side or become generalized.side or become generalized.
Rarely may continue for hours or day Rarely may continue for hours or day (epilepsia partialis continue).(epilepsia partialis continue).
After the attack, there may be weakness of After the attack, there may be weakness of the part involved (Todd's) paralysis.the part involved (Todd's) paralysis.
Sensory Sensory seizures:-seizures:- (simple partial (simple partial sensory seizures):-sensory seizures):-
Localized or spreading parasethesia:- Localized or spreading parasethesia:- tingling, coldness, numbness electricity or tingling, coldness, numbness electricity or even pain.even pain.
Autonomic Autonomic seizures-seizures- (simple partial (simple partial autonomic seizures):-autonomic seizures):-
Autonomic manifestationAutonomic manifestation::
-Sweating. - Tachycardia.-Sweating. - Tachycardia. Diarrhea or Constipation. Diarrhea or Constipation. Hypertension.Hypertension. Abdominal pain (abdominal epilepsy). Abdominal pain (abdominal epilepsy). Pupillary dilatation or constriction.Pupillary dilatation or constriction.
Temporal lobe (psychomotor)Temporal lobe (psychomotor)Partial complex epilepsyPartial complex epilepsySequence of events:-Sequence of events:-
Aura:- blinking of eyes, abnormal sound, Aura:- blinking of eyes, abnormal sound, taste, smell or movement.taste, smell or movement.
Absence:- loss of consciousness.Absence:- loss of consciousness. Automatism:- automatic movements e.g: Automatism:- automatic movements e.g:
chewing, smacking of lips.chewing, smacking of lips. Amnesia:- recent amnesia for all events Amnesia:- recent amnesia for all events
during the attack.during the attack.
Treatment of epilepsyTreatment of epilepsyDuration of therapy:- Duration of therapy:-
3 or 4 years after the last convulsions in 3 or 4 years after the last convulsions in grand-mal or petit mal epilepsy in an grand-mal or petit mal epilepsy in an otherwise normal child.otherwise normal child.
Longer period or even life long for those with Longer period or even life long for those with associated neurological problems.associated neurological problems.
Advice to parents & child:-Advice to parents & child:- Give full information about the drug Give full information about the drug
therapy and stress on therapy and stress on not to stop not to stop the drugthe drug without medical advice. without medical advice.
Allow normal activities:- the child Allow normal activities:- the child should be attended by a responsible should be attended by a responsible adult while bathing or swimming.adult while bathing or swimming.
Give clear instructions about the first-Give clear instructions about the first-aid measures in case the seizures: aid measures in case the seizures:
1.1. Ensure patent airway. Ensure patent airway.
2.2. Avoid biting the tongue Avoid biting the tongue
3.3. Putting the child in the prone or side Putting the child in the prone or side position with head down.position with head down.
Anticonvulsants:Anticonvulsants:
Type of Type of seizuresseizures
Drug of Drug of choicechoice
Daily doseDaily doseSide effectsSide effects
NeonatalNeonatalPhenobarbitoPhenobarbitonene
3-5 mg/kg3-5 mg/kgIrritability,overactiIrritability,overactivityvity
Grand-malGrand-malNa-Valproat, Na-Valproat, Phentoin, Phentoin,
CarpamazepiCarpamazepinene
10-20mg/kg 10-20mg/kg 4- 4-8mg/kg 8mg/kg
10-20mg/kg10-20mg/kg
-Hepatic -Hepatic dysfunction dysfunction -Ataxia,gum -Ataxia,gum hypertrophy. hypertrophy. -Rash, Leucopenia, -Rash, Leucopenia, hepatic hepatic dysfunctiondysfunction
Focal motorFocal motorCarpamazepiCarpamazepinene
4-8mg/kg4-8mg/kgRash, Leucopenia, Rash, Leucopenia, hepatic hepatic dysfunctiondysfunction
PsychomotorPsychomotorCarpamazepiCarpamazepinene
4-8mg/kg4-8mg/kgRash, Leucopenia, Rash, Leucopenia, hepatic hepatic dysfunctiondysfunction
Myoclonic, Myoclonic, Akinetic Akinetic
ClonazepamClonazepam0.05-0.05-0.2mg/kg0.2mg/kg
Drowsiness, Drowsiness, salivation, salivation, sedationsedation
Petit-malPetit-malEthosuximideEthosuximide20-40mg/kg20-40mg/kgRash, Leucopenia, Rash, Leucopenia, hepatic hepatic dysfunctiondysfunction
Status Status EpilepticusEpilepticus
DiazepamDiazepam0.2-0.4mg/0.2-0.4mg/kgkg
Respiratory Respiratory depressiondepression
New drugs used for treatment of New drugs used for treatment of epilepsy:epilepsy:
-For-For generalized generalized seizures: seizures:• LamotrigineLamotrigine• TopiramateTopiramate• ZonisamideZonisamide-For -For partialpartial seizures: seizures:*Gabapentine*Gabapentine--ForFor Infatile spasm:Infatile spasm:*Topiramate*Topiramate*Vigabatrin*Vigabatrin
PoisoningPoisoning, , drug abusedrug abuse, and , and alcohol intoxicationalcohol intoxication
The most commonly drugs in The most commonly drugs in suicide attempts aresuicide attempts are : :
1.1. BenzodiazepinesBenzodiazepines2.2. ParacetamolParacetamol3.3. antidepressantsantidepressants. . Narcotic overdosesNarcotic overdoses (heroin)(heroin) 1.1. Pinpoint pupilsPinpoint pupils2.2. Shallow respirationsShallow respirations , , needle marksneedle marks. . 3.3. The coma is easily reversible with The coma is easily reversible with
naloxonenaloxone
Alcohol intoxicationAlcohol intoxication Apparent from the Apparent from the historyhistory, , flushed flushed
faceface, , rapid pulserapid pulse, and , and low blood low blood pressurepressure. The . The smell of alcoholsmell of alcohol on the on the breath.breath.
Intoxicated are at increased risk of Intoxicated are at increased risk of hypothermia and of head injuryhypothermia and of head injury can be can be the cause of coma. the cause of coma.
At low plasma concentrationsAt low plasma concentrations of of alcoholalcohol, , mental changesmental changes, , at higher at higher levelslevels, , comacoma ensues, >350 mg/dl may ensues, >350 mg/dl may prove prove fatalfatal..