ACUTE CONFUSIONAL

STATES AND COMA

Confusional states and coma are
among the most common
problems in general medicine. It is
estimated that over 5% of
admissions to the emergency
ward of large busy hospitals are
due to diseases that cause a
disorder of consciousness.
These conditions can take the
form of drowsiness, stupor or
coma.
 UNDERSTANDING THE
MECHANISM OF COMA
 Consciousness or alertness is
maintained by brainstem and
thalamic neurons, the reticular
activating system and it’s
connections to the cerebral
hemispheres.
 therefore structural
brainstem and thalamic
lesions bring the patient more
likely into coma compared to
supratentorial (cerebral)
lesions.
 STRUCTURAL LESIONS
 are responsible for about 35 % of
causes of coma, e.g.
- CVA
- Head injuries
- Brain tumors
- SAH
 METABOLIC CONDITIONS: affect the
brain globally and constitute about 65
% of causes e.g.

* DKA
* Hyperosmolar coma
* Hypoglycemia
* Hepatic coma
* Uremia
* Hyponatremia <115 meq/L
* Hypercalcemia
 OTHER CAUSES:
 Post ictal state
 Cardiac
 Respiratory
 Hypocalcemia
 Septicemia
 Encephalitis
 Meningitis
 Wernick’s encephalopathy
 Vitamin B12 deficiency
 Heat stroke
 Hypothermia
 Myxoedema
 Drug overdose
 Organophosphorous poisoning
APPROACH TO THE PATIENT
 HISTORY
 LIFE THREATENING CONDITIONS
SHOULD BE ATTENDED FIRST:
 ABC
 CONSIDER GIVING:
- Oxygen
- D50
- Naloxone
- Thiamine
- Few drugs have antidotes
- Treat arrhythmias
- Give fluids if indicated
 ASSESS:
 Temperature
 Blood pressure
 Breathing & respiration
 Pupillary reactions
 Fundoscopy
 Level of consciousness
 Using the AVPU or GCS
 Localizing signs
 Patient should be nursed on the semi-
prone position
 Correct hypothermia and hyperthermia
 THE IDEA IS TO PREVENT
FURTHER BRAIN DAMAGE.

 WHEN LABORATORY
INVESTIGATIONS ARE
AVAILABLE CORRECT
HYPERCALCEMIA AND
ELECTROLYTE
DISTURBANCES.
 LABORATORY
INVESTIGATIONS:
 CBC
 RBS
 RFT
 LFT
 URINALYSIS & CULTURE
 BLOOD CULTURE
 OSMOLALITY
 ABG
 BLOOD GROUP & CROSSMATCHING
 CHEST X-RAY
 CT BRAIN
 LUMBAR PUNCTURE
 COMA LIKE SYNDROME:

 Psychogenic unresponsiveness
 The vegetative state

 Brain death
 ASSESS BRAIN STEM
FUNCTION
 Corneal reflex
 The gag reflex
 Cough reflex
 The doll’s head maneuver
 The ice water caloric test
 CONSIDER:
 Basilar artery thrombosis
 Cerebellar hemorrhage
 Pituitary apoplexy
* thrombotic thearapy for basilar
artery
thrombosis
* urgent surgery for cerebellar
hemorrhage and pituitary
apoplexy
* ventricular puncture for acute
hydrocephalus
PROGNOSIS
THANK YOU!
DR. ABDLR
MUSTAFA