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(consciousness)
Dr Antony Thomas
Consultant Neurologist
UHCW
Alexandra Hospital
Redditch
Neural basis of
consciousness
Consciousness
cannot be
readily defined in terms of
anything else
Mental
Status =
Arousal + Content
Change in content
Psychogenic
unresponsiveness
Locked in syndrome
Vegetative
Locked-in
Confusional state
Delirium
1.
2.
3.
4.
5.
Toxins
metabolic disorders
partial complex seizures
head trauma
acute febrile systemic illnesses
4 Eyes opening
Best verbal
response (V)
Best motor
response (M)
5 Oriented
6 Obeys commands
4 Confused
5 Localizes to pain
3 Inappropriate
4 Withdraws from
words
pain
2 Incomprehensible
3 Flexion in response
sounds
to pain
1 None
2 Extension to pain
spontaneously
3 Eye opening to
speech
2 Eye opening in
response to pain
1 No eye opening
1 No motor response
Approaches to DD
Unresponsive
ABCs
Glucose, ABG, Lytes,
Mg, Ca, Tox,
ammonia
Y
IV D50, narcan,
flumazenil
Brainstem N
or other
Focal signs
Y
CT
Unconscious
Pseudo-Coma
Psychogenic,
Looked-in,
NM paralysis
LP CT
Approaches to DD
General examination:
On arrival to ER immediate attention to:
1. Airway
2. Circulation
3. establishing IV access
4. Blood should be withdrawn:
estimation of glucose # other
biochemical parameters # drug
screening
Epilepsy
DM, Drug history
Clothing or
Handbag
2.
Temperature
Hypothermia
Hypopituitarism, Hypothyroidism
Chlorpromazine
Exposure to low temperature
environments, cold-water
immersion
Risk of hypothermia in the
elderly with inadequately heated
rooms, exacerbated by
1.
2.
Pulse
Blood Pressure
Skin
Pupils
Diencephalons
Small, reactive
Midbrain
Medium-sized, fixed
Dilated, Fixed
Pons
small, pinpoint
In hge reactive
.
Odour of breath
Acetone: DKA
Fetor Hepaticus: in hepatic coma
Urineferous odour: in uremic coma
Alcohol odour: in alcohol intoxication
Respiration
CheyneStokes respiration:
(hyperpnoea alternates with
apneas) is commonly found in
comatose patients, often with
cerebral disease, but is relatively
non-specific.
Rapid, regular respiration is also
common in comatose patients and is
often found with pneumonia or
acidosis.
Apneustic breathing
Brainstem lesions Pons may also
give with a pause at full
inspiration
Ataxic:
Medullary lesions: irregular
respiration with random deep
and shallow breaths
Cheyne-Stocks
Cluster
Ataxic
Midbrain
Apneustic
Pons
Ataxic
Medulla
ARAS
Motor function
Flexion of the
upper limb with
extension of the
lower limb
(decorticate
response) and
extension of the
upper and lower
limb (decerebrate
response)
indicate a more
severe
disturbance and
Signs of lateralization
Unequal pupils
Deviation of the eyes to one side
Facial asymmetry
Turning of the head to one side
Unilateral hypo-hypertonia
Asymmetric deep reflexes
Unilateral extensor plantar response
(Babinski)
1.
2.
The head
Evidence of injury
Skull should be palpated for
depressed fractures.
The ears and nose: haemorrhage
and leakage of CSF
The fundi: papilloedema or
subhyaloid or retinal haemorrhages
1.
2.
Causes of
COMA
Mechanism:
Impairment of perfusion of the RAS
With hypotension
Subarachnoid haemorrhage
Parenchymal haemorrhage
1.
2.
1.
2.
Hypotension
1.
2.
Hypertensive encephalopathy
Head injury
Infections
Epileptic Seizures
Raised ICP ( Posterior Fossa tumours,
hydrocephalus)
Sleep disorders
Stroke
Basilar Artery Migraine
Others
Cardiac arrhythmia
HOCM
PE
AS
Pituitary Failure
Pituitary Apoplexy
Myxedema Coma
Hyperthyroidism
Adrenocortical Failure
Ca, Mg metabolism
Hypo & Hyper Ca
Hypo & Hyper Mg
Seizures
Definition:-
Etiology:-
Classification:-
Acute non recurrent convulsions:One or more convulsive fits that occur during the same
acute illness & do not recur after recovery:
Epilepsy
Defined as Increased Neuronal
Excitability
No loss of consciousness:
Motor Sensory Autonomic.
Loss of Consciousness: Temporal lobe epilepsy.
Febrile convulsion
Definition:- Generalized tonic clonic
convulsions which occasionally occur at
the onset of acute extra-cranial infections.
Incidence:- 3-5% in all children.
Etiology:-
Clinical picture:-
free.
Investigation
Laboratory:CSF analysis: Indicated if any doubt
exist regarding the possibility of
meningitis.
EEG:- Indicated in atypical febrile seizure
Myoclonic epilepsy
- Occurs at any age but is more seen in infants and
young children.
- Usually associated with mental retardation.
-The attack which is very frequent, present with
sudden symmetrical mass jerking involving all
limbs.
Status epilepticus
Definition:Continuous convulsion or repeated
convulsions without return of the level of
consciousness more than 20 min.
Causes:-Sudden withdrawal of anticonvulsant.
-Febrile convulsion in poorly controlled
epileptic patient.
-Metabolic or toxic.
Management:
1-Stop the convulsion by:- Diazepam 0.2 0.4mg / kg / dose I.V. or
0.5mg/kg/dose rectally.
- Chloral hydrate or paraldehyde:- 0.15 mg/kg
diluted in saline I.V or 0.5ml/kg/dose rectally
- If failed give general anesthesia (short acting
barbiturates).
2-Long-term anticonvulsant: Phenobarbitone 3-5mg/kg/day.
Diphenylhydantoin 5-8mg/kg/day.
3-Evaluation of the patient:
After the
attack Todd's paralysis may occur and then
resolve completely.
Motor :
Jacksonian epilepsy
(simple partial motor seizures): Involve the motor area of the brain and the
patient is alert.
Consists of clonic movements in a localized
group of muscles. Commonly at the Corner
of mouth, Thumb, and Great toe.
Jacksonian march:- The neuronal discharge
may spread to other parts on the same side
or become generalized.
Rarely may continue for hours or day
(epilepsia partialis continue).
After the attack, there may be weakness of
the part involved (Todd's) paralysis.
Treatment of epilepsy
1.
2.
3.
Anticonvulsants:
Type of
seizures
Drug of
choice
Daily dose
Side effects
Neonatal
Phenobarbito
ne
3-5 mg/kg
Irritability,overacti
vity
Grand-mal
Na-Valproat,
Phentoin,
10-20mg/kg -Hepatic
dysfunction
4-Ataxia,gum
8mg/kg
hypertrophy.
-Rash, Leucopenia,
hepatic
10-20mg/kg dysfunction
Carpamazepi
ne
Focal motor
Carpamazepi
ne
4-8mg/kg
Rash, Leucopenia,
hepatic
dysfunction
Psychomotor
Carpamazepi
ne
4-8mg/kg
Rash, Leucopenia,
hepatic
dysfunction
Myoclonic,
Clonazepam
0.05-
Drowsiness,
1.
2.
3.
1.
2.
3.
Alcohol intoxication
Apparent from the history, flushed
face, rapid pulse, and low blood
pressure. The smell of alcohol on the
breath.
Intoxicated are at increased risk of
hypothermia and of head injury can be
the cause of coma.
At low plasma concentrations of
alcohol, mental changes, at higher
levels, coma ensues, >350 mg/dl may
prove fatal.