consciousness state of wakefulness with awareness of self and surrounding. confusion altered...
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ConsciousnessState of wakefulness with awareness of
self and surrounding .
ConfusionAltered consciousness (the subject
misinterprets his surrounding) .
Deliriumstate of high arousal ( acute confusion )
There is confusion and visual hallucination .
Stupor
Is abnormal sleepy stat from which the subject can be aroused by repeated stimuli .
Coma ( or unconsciousness )
Is a state in which a patient is totally unaware of both self and external surroundings.
Coma is not a disease. It is a symptom of disease or a response to an event.
Pathophysiology:
A reduction in neuronal function resulting from disruption of cerebral cortical or brain stem integrity.
* Encephalopathy: hypoxia ischemia seizures and post ictal states
* Infection: encephalitis meningitis septicemia
* Pressure effects: cerebral edema hydrocephalus space occupying lesions
* Vascular:- hemorrhage : extradural, subdural, subarachnoid, intraventricullar- hypertensive encephalopathy
* Diseases of other systems:- hepatic coma- uremic encephalopathy- respiratory failure with C02 narcosis
* Endocrine:- adrenal insufficiency- DKA / hypoglycemia- hypothyroidism- hypopituitarism
* Exogenous intoxication:- sedatives- salicylates- heavy metals- carbon monoxide
* Fluid and acid-base balance:- H20, Na, K, Mg and Ca imbalance
* Trauma.
History
Infection:Fever, irritability, lethargy, poor feeding, rash,
seizure.
Metabolic:Hx of DM, hx of previous loss of consciousness, hepatomegaly, jaundice, oligurea, hypertension.
Poisoning:Ask about drugs in the family, tablets, and
alcohol.
Seizure:Past hx of seizure, neurocutaneous lesions,
developmental delay, abnormal eye movement, focal neurological signs.
Trauma:Hx of road traffic accident, fall, bruising, hemorrhage,
fractures.
Raised intracranial pressure:Headache, vomiting,
focal neurological signs: ataxia, squint.
Papilloedema, retinal hemorrhage.
Physical Examination
General Examination
Neurological Examination
In General Examination:
Vital Signs:-
IRREGULAR – Cardiac diseases ABSENT – Peripheral emboliFEEBLE – Circulatory collapse
PULSE
BLOOD PRESSURE
-CVA -hypertensive
encephalopathy
-Cardiogenic shock
-Septicemia -Addison’s disease
TEMPERATURE
FEVER
HYPOTHERMIA
-Drugs : Barbiturate -Circulatory failure
-Myxoedema
-Systemic infection : malaria -Meningitis / encephalitis
-Heat stroke
CYANOSICYANOSISS
JAUNDICJAUNDICEE
PURPURPURPURAA
SKIN SKIN RASHRASH
Skin and mucous membranes-:
Head - scalp-:
fractures, hematomas ,ant fontanels.
ENT-:
discharge, blood
Fundoscopy
Neck - Cx. Spine-:
fracture, neck stiffness, carotid pulses
Neurological examination
Determine level of consciousness by
GCS
* The Glasgow Coma Scale is used to determine the severity of a brain injury. It is often used at the emergency scene or emergency room.
* The scale is used as part of the initial evaluation of a patient, but does not assist in making the diagnosis the cause of coma
* Motor, verbal, and eye responses are rated.
Eye Opening
Spontaneous
To loud voice
To pain
None
Spontaneous
To loud voice
To pain
None
4
3
2
1
Verbal Response
Oriented
disoriented and converses
inappropriate words
Incomprehensible sounds
None
smile, follows objects .
spontaneous irritable cry
Cries only to pain
Moans to pain
None
5
4
3
2
1
Motor Response
Obeys commands
Localizes pain
Withdraws from pain
Abnormal flexion (decorticate posture)
Abnormal Extension (decerebrate posture)
None
Obeys commands
Localizes pain
Withdraws from pain
Abnormal flexion (decorticate posture)
AbnormalExtension (decerebrate posture)
None
6
5
4
3
2
1
GCS
Mild=13-15
Moderate=9-12
Severe=3-8
Minimum=3 - Maximum=15
Core Neurological Exam (for coma);
1)Respiratory rate
2)Pupil
3)Extra ocular muscle, function muscle
4)Motor exam
5)Ciliospinal reflexes
Supra-orbital nail-bed sternum
METHODS OF ELICITING MOTOR RESPONSE
MOTOR RESPONSEMOTOR RESPONSE
PUPILS – SIZE AND REACTION TO LIGHTPUPILS – SIZE AND REACTION TO LIGHT
Normal, reactive
DIENCEPHALICDIENCEPHALICSmall, reactive MIDBRAINMIDBRAIN
Large, fixed
III NERVE (UNCAL)III NERVE (UNCAL) dilated, fixed
PONSPONSpinpoint
METABOLICMETABOLIC
yes yes (brain (brain stem intact)stem intact)
no no (brain stem (brain stem damage)damage)
- Chyne-Stoke breathing (cerebral Chyne-Stoke breathing (cerebral hemisphere lesion)hemisphere lesion)
- Central Neurogenic - Central Neurogenic Hyperventilation (midbrain) Hyperventilation (midbrain)
- Apneustic breathing (pons) - Apneustic breathing (pons)
- Ataxic breathing – gasping - Ataxic breathing – gasping (medulla)(medulla)
Drugs screen(eg_salicylates --diazepam-narcotics-amphetamines)
-Routine biochemistry (urea-electrolytes-glucose-calcium-liver biochemistry)
-Metabolic and endocrine studies (TSH-serum cortisol)
-Blood cultures such as cerebral malaria(thick blood film)
-If the explanation remains unclear ,further investigation are needed.
INVESTIGATION
IMAGING
CT or MRI brain imaging may indicate an otherwise unsuspected mass lesion or
intracranial hemorrhage.
CSF examination
Lumber puncture should be performed in coma only after careful risk assessment .it is usually contraindicated when an intracranial mass lesion is a possibility .CT is necessary to exclude this. CSF examination is likely to alter therapy only if undiagnosed meningoencephalitis or other identifiable
infection is present.
lumbar lumbar puncturepuncture.….…
Electroencephalography
EEG is of some value in the diagnosis of metabolic coma and encephalitis .
Management of comatose patient
Immediate Therapy
Specific Therapy
AA
BB
CC
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