Alteration of Consciousness in I.C.U & e.r departments

1. Alteration of Consciousness in I.C.U & e.r departments Prof., Dr. :sherif wadie

2. Reticular activating system (RAS)

3. Good Consciousness = Alertness + Awareness

4. Diminished alertness = Widespread abnormalities of cerebral hemispheres or reduced activity of reticular activating system (RAS)

5. Definition of Terms • Confusion : • Impaired attention and concentration, manifest disorientation in time, place and person, impersistent thinking, speech and performance, reduced comprehension and capacity to reason • Fluctuate in severity, typically worse at night ‘sundowning’ • Perceptual disturbances and misinterpret voices, common objects and actions of other persons • Confusion is also found in dementia (progressive failure of language, memory, and other intellectual functions)

6. Definition of Terms • Delirium : confusion and associated agitation, hallucination, convulsion and tremor • Amnesia : a loss of past memories and to an ability to form new ones, despite alert and normal attentiveness

7. Level of Consciousness(1) • Alert  : normal awake and responsive state • Drowsiness : state of apparent sleep, briefly arousal with oral command • Lethargic :resembles sleepiness, but not becoming fully alert, slow verbal response and inattentive. Unable to adequately perform simple concentration task (such as counting 20 to 1)

8. Level of Consciousness (2) • Somnolent :  easily aroused by voice or touch; awakens 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

9. Dementia VS Confusional state • Dementia • Longstanding nature • Varies little from time to time • Memory problem • Confusional state • Acute • Fluctuate • Clouding of consciousness

10. Causes of confusional state(1) Medical or surgical disease • Metabolic disorders • Hepatic • Uremic • Hypo and hypernatremia • Hypercalcemia • Hypo and hyperglycemia • Hypoxia • Hypercapnia

11. Causes of confusional state(2) • Infectious illness • Pneumonia • Endocarditis • Urinary tract infection • Peritonitis • Congestive heart failure • Postoperative and posttraumatic states

12. Causes of confusional state(3) Drug intoxication • Opiates • Barbiturates • Other sedatives

13. Causes of confusional state(4) Diseases of nervous system • Cerebrovascular disease, tumor, abscess • Subdural hematoma • Meningitis • Encephalitis • Cerebral vasculitis • Hypertensive encephalopathy

14. causes of confusional state (5) •Alcoholism. •Depression. •Diabetes. •Drug overdose •Head injuries •Encephalitis •Epilepsy •Stroke

15. Approach • History --- emphasizing the patient’s condition before the onset of confusion • Clinical examination --- focus on • signs of diminished attentiveness, disorientation, and drowsiness and • the presence of localizing neurological signs

16. Aim of carein confusion patients • Control underlying medical illness • Quiet the patient and protect him from injury • Discontinue drugs that could possibly be responsible for the acute confusional state : sedating, antianxiety, narcotic, anticholinergic, antispasticity, corticosteroid, L-dopa, metoclopramide, cimetidine, antidepressant, antiarrhythmic, anticonvulsant, antibiotics.

17. Medical management • Haloperidol, quetiapine, risperidone are helpful in calming the agitated and hallucinating patient, but should be used in the lowest effective doses • In alcohol or sedative withdrawal—chlordiazepoxide is the drug of choice. Chloral hydrate, lorazepam, and diazepam are equally effective

18. COMA

19. GLASGOW COMA SCORE Eye opening: Nil 1 To pain (applied to limbs) 2 To voice (including command) 3 Spontaneous (with blinking) 4 Motor response: Nil 1 Arm extension to pain (nail bed pressure) 2 Arm flexion to pain (nail bed pressure) 3 Arm withdrawal from pain (nail bed pressure) 4 Hand localizes pain(supraorbital or chest pressure) 5 Obeys commands 6 Verbal response: NIL 1 Groans (no re-cognizable words) 2 Inappropriate words (including expletives) 3 Confused speech 4Orientated 5

20. Glasgow Coma Scale : Eye opening (E)

21. Glasgow Coma Scale : Motor response (M)

22. Glasgow Coma Scale : Verbal response (V)

23. GLASGOW COMA SCORE Notes • scoring from the best response • verbal response will not correct in the condition of aphasia, intubation and facial injury • sensory loss may interfere painful stimulation • eye opening may be interfered by orbital swelling and 3rd CN palsy • arm movements may be impaired from local trauma or cervical cord lesion

24. Approach to the patient • History • Circumstances and rapidity with which neurologic symptoms developed • Immediately preceding medical and neurologic symptoms • Use of medications, illicit drugs, or alcohol • Chronic liver, kidney, lung, heart, or other medical disease

25. General physical examination • Vital sign • Temperature • Fever • Hypothermia -- <31°C causes coma • Pulse • Respiratory rate and pattern • Blood pressure • Funduscopic examination • Cutaneous lesion

26. Neurologic assessment • Observe • Movement : restless, twitching, multifocal myoclonus, asterisks • Decorticate rigidity Suggest severe bilateral damage rostral to midbrain • Decerebrate rigidity Indicate damage to motor tracts in the midbrain or caudal diencephalon

27. Decorticate posture results from damage to one or both corticospinal tracts

28. Decerebrate posture results from damage to the upper brain stem

29. Neurologic assessment • Level of arousal and elicited movements • Brainstem reflexes • pupils • Ocular movements • respiration

30. Pupils in comatose patients DESCRIPTIONSINTERPRETATION Small, reactive Metabolic causes Diencephalic lesion Midposition, fixed Mid brain lesion large, fixed Extensive brain stem lesion Anoxia Sedative overdose Anticholinergic poisoning or mydriatic eyedrops Pin point Pontine lesion Opiates Unilateral fixed dilated Third nerve palsy

32. Doll’s eye maneuver (Oculocephalic reflex) Cold caloric test (Oculovestibular reflex)

34. Eye movements

35. Respiratory patterns

36. Respiratory pattern(1) • Cheyne-Stokes respiration : bilateral cortical or bilateral thalamic lesions, metabolic disturbances, incipient transtentorial herniation • Hyperventilation : midbrain or pons lesions • Apneusis : lateral tegmentum of lower half of pons • Cluster : lower pontine or high medullary lesions • Ataxic : dorsomedial medulla lesion

37. Respiratory pattern(2) • Least useful sign because : • Acid-base derangements • Hypoxia • Cardiac influences

38. Conditions mimic coma • Brain death • Locked-in syndrome • Vegetative state • Frontal lobe disease • Non-convulsive status epilepticus • Psychiatric disorder (catatonia, depression)

39. Vegetative state • An awake but unresponsive state • Extensive damage in both cerebral hemisphere • Retained respiratory and autonomic functions • Cardiac arrest and head injury are the most common causes.

40. Locked-in state • Awake patient has no means of producing speech or volitional limb, face and pharyngeal movements • Vertical eye movement and lid elevation remain unimpaired • Infarction or hemorrhage of the ventral pons

41. COMA LOCALIZING SIGN NO LOCALIZING SIGN SUPRATENTORIAL INFRATENTORIAL STIFF NECK - CVD - TUMOUR - ABSCESS - SAH - MENINGITIS NO STIFF NECK STRUCTURAL DAMAGE FUNCTIONAL NEURONAL DEPRESSION - HYPOXIA - CARDIAC ARREST - ENCEPHALITIS - HEPATIC - URAEMIC - POST ICTAL STATE - FLUID ELECTROLYTE IMBALANCE - DRUGS

42. Blood test • CBC • FBS • BUN, Creatinine • Electrolyte, calcium • LFT • Drug screen, toxicology screen

43. Other tests • EKG • CT or MRI brain • CSF exam • EEG

44. Prognosis 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

45. Brain Herniation • Central transtentorial herniation

46. Brain Herniation • Uncaltranstentorial herniation

47. Management of Transtentorial herniation • Intubation andhyperventilation (PCO2 25-30 mmHg) • Mannitol (0.5-1 gm/kg body weight or20% mannitol 200 cc. infusion 10-20 minutes repeat every 4 hours if necessary • Furosemide 20-40mg IV • Dexamethasone 4-10 mg IV q 6 hours decrease perilesional vasogenic cerebral edema. Active at 24-48 hours. • Consult surgery