Acute Confusional States & Coma PDF

Acute Confusional States & Coma  Introduc5on De7ni5on of Consciousness: - Consciousness or conscious state or conscious self or conscious mind refers to a state of cerebral arousal which allows the brain to executes it’s func7ons of sensory percep7on of data i...

Acute Confusional States & Coma  Introduc5on De7ni5on of Consciousness: - Consciousness or conscious state or conscious self or conscious mind refers to a state of cerebral arousal which allows the brain to executes it’s func7ons of sensory percep7on of data input to it from the 5 common senses. - It refers to all percep.ons, memories, feeling, free well, ideas & fantasies …… that we currently apprecia.ng. - It is non-spa.al en.ty that has no direct loca.on in space (spa.al =eld) but has existence in temporal =eld. We can give it a loca.on in space indirectly by link it to her/him genera.ng brain.  “Brain - consciousness” rela5onship: ‒ Conscious mind is the product of brain, i.e. the brain is the generator of consciousness. ‒ Though the conscious mind is a spine of brain, but it is not just an epiphenomenon of brain physiology, i.e. not all it’s aspects can be reduced to physiology of brain. ‒ It is of dual nature containing elements which are merely reJec.ons to brain ac.vi.es & other elements which represent a pure psychic func.ons that represent a pure mental ac.vi.es of consciousness not related to brain physiology, like an.-da.ng phenomenon. ‒ This mean that there is a bi-traKc way between the brain & the conscious mind. From material brain to consciousness (like energy to maMer) as in sensory percep.on, & from consciousness, back, to brain (like maMer to energy) as in ac.on of conscious self over the brain in voluntary movements & aMen.on. ‒ In the usual condi.ons this mutual rela.on happen between conscious mind & her/his genera.ng brain, not with other material en..es. ‒ consciousness must contain such pure psychic (non- brain) phenomena because it represent a new (completely new) level of organic evolu.on. ‒ If it involves just phenomena that represent reJec.ons of the brain ac.vi.es, this mean that it is a passive en.ty which mean that it is a non-adop.ve character. This completely counter duct with laws of organic evolu.on, because from evolu.onary point of view the consciousness has a survival (adop.ve) value to the organism by allowing it to interact more eKciently with environment e.g. feeling pain from burn make you escape from =re. ‒ It represent merely a higher (in fact the highest known) level of organic evolu.on.  ‫ ﻋﺪا اﻟﺘﻌﺮﯾﻒ اﻟﻲ اﺷﺮﺗﮫ‬،‫اﻟﺪﻛﺘﻮر ﻛﺎل اﻟﺴﻼﯾﺪات اﻟﺴﺎﺑﻘﺔ ﻏﯿﺮ ﻣﻄﻠﻮﺑﺔ ﺑﺎﻻﻣﺘﺤﺎن ﻟﻜﻦ اطﻠﻌﻮا ﻋﻠﯿﮭﺎ‬ Genera7on of conscious state depend on ac7vity of a part from the re7cular forma7on of brain called the ascending re7cular ac7va7ng system (A.R.A.S) of midbrain. A.R.A.S terminated proximally in the non-speciDc thalamic nuclei (intra-laminary & midline thalamic nuclei) which project, in turn, non-speciDcally to the cerebral cortex. Note ; There is no anatomical confirmation, rather only physiological evidence Ac7vity of this system act to generate a state of de- synchroniza7ons in cerebral cortex, which is necessary for execu7on of sensory percep7ons & genera7on of consciousness. # synchronizations activity in cerebral cortex, Leads to same activity everywhere in the cortex, brain loss it ability to perception = You sleep = While de synchronizations in cerebral cortex, not same activity in cortex, leads to generation of consciousness. = You awake So, Disorders that affect consciousness, it affect it through affecting ARAS What is the Nature of Consciousness? It is s.ll unknown. It is an en.ty of unknown nature like.me. Sigmund Freud said what mean: “study consciousness without.red yourself in the ques.on of what is it’s nature, as for physicists who study the.me & discover it’s laws without knowing exactly what is the.me”. The ques.on of “what is the nature of consciousness” is, as for the ques.ons of what is the nature of.me, remain a duty for future researches & discoveries.  Disturbances of Level of Consciousness Normal level of consciousness: - Constant level of consciousness (no Juctua.on = clear conscious stream) - Oriented in space,.me & person - No hallucina.ons, no irritability We have 2 major categories of disturb consciousness: 1) Hyper-consciousness: in anxiety, in attentional deficit disorder (minimal brain damage) ⑤ - Same of above but there is irritability. Only - irritability, but No hallucinations, no irritability, no fluctuation in level of consciousness 2) Lowering level of consciousness: - Vary from: drowsiness, obtanda.on, confusion, delirium, stupor, semi coma, to coma. N.B: disturbances in level of consciousness result from disorders of or adverse eYects on A.R.A.S of mid-brain.  Dr : can occur due to any cause & so investigation is also any & so Treatment is also according to the “any” cause: -> any. o Acute Confusion any abnormal pose ① Trngestigating"are cause It is a state characterized by: 1. Disorienta.on in space &.me, -You ask him to answer Raise but 2. Fluctua.ng level of consciousness & clouding of sensorium, the consciousness in morning differs from night, from today to next day 3. Acute onset & resent course. Acute suden Graduate: Post Acuty:2d Sd. subacute, days 9$ it According to Who, in USA system both are same ⑰ If hallucina.ons (usually visual) supper added to - Hallucinations are usually visual in organic diseases the above feature, the condi.on termed “delirium”.  dis"s es y'58y!.-6,s According to the cause Clinical Features Helpful in the Di3eren4al Diagnosis of Acute Confusional States: or 1) Headache: Head trauma, meningi.s, subarachnoid hemorrhage. I HTN 2) Vital signs: - Fever: Infec.ous meningi.s, an.cholinergic intoxica.on, withdrawal from ethanol or seda.ve drugs, sepsis. - Hypothermia: Intoxica.on with ethanol or seda.ve drugs, hepa.c encephalopathy, hypoglycemia, hypothyroidism, sepsis. - Hypertension: An.cholinergic intoxica.on, withdrawal from ethanol or seda.ve drugs, hypertensive encephalopathy, subarachnoid hemorrhage, sympathomime.c intoxica.on. - Tachycardia: An.cholinergic intoxica.on, withdrawal from ethanol or seda.ve drugs, thyrotoxicosis, sepsis. - Bradycardia: Hypothyroidism. - Hyperven.la.on: Hepa.c encephalopathy, hyperglycemia, sepsis. - Hypoven.la.on: Intoxica.on with ethanol or seda.ve drugs, opioid intoxica.on, pulmonary encephalopathy. 3) General examina.on: Intra cerebral - Meningismus: Meningi.s, subarachnoid hemorrhage Fever, Fit and behavioral disturbances hemorrhage. Encephalitis with negative History of Psychiatric suspect there is encephalitis - Skin rash: Meningococcal meningi.s. or Steven Jenson syndrome - Tetany: Hypocalcemia. Psoriasis, severe case, either by it or by one of it’s drugs also can cause acute confusional attack  4) Cranial nerves: - Papilledema: Hypertensive encephalopathy, SOL intracranial mass.eg: O ② Hydatid cyst, Toxoplasmosis Tumer Or Respiratory failure causing sign of disc swelling, Papilledema like (not Papilledema) or hematological disorder 9 - Dilated pupils: Head trauma, Oan.cholinergic & Alcohol ③ intoxica.on, withdrawal from ethanol or seda.ve ⑪ drugs, sympathomime.c intoxica.on. ‫ ذوﻟﺔ اﻻرﺑﻌﺔ اﺣﻔﻆ اﻻوﻓﺮ دوز‬: ‫د‬ ‫ﺷﯿﺴﻮي و اﺣﻔﻆ اﻟﻮذدراول ﺷﯿﺴﻮي‬ - Constricted pupils: Opioid intoxica.on. - Nystagmus/ophthalmoplegia: Intoxica.on with ethanol, seda.ve drugs, or phencyclidine, vertebrobasilar ischemia, Wernicke encephalopathy.  5) Motor: - Tremor: Withdrawal from ethanol or seda.ve drugs, sympathomime.c intoxica.on, overdose thyrotoxicosis. Valproic acid (Debakin) overdoses, Valium (Diazepam) over dose, Zanax cause muscle twitch then flickering in 6t muscles, E ⑭- Asterixis: Metabolic encephalopathy. ther then tremor Hepatic, Renal & Congestive Heart Failure at end cause GROUP of drugs ; Narcotic Drug poisoning (this drugs used in CCU) convulsion - Hemiparesis: Cerebral infarc.on, head trauma, hyperglycemia, hypoglycemia. - 5) Other: - Seizures: withdrawal from ethanol or seda.ve drugs, head trauma, hyperglycemia, hypoglycemia. - Ataxia: intoxica.on with ethanol or seda.ve drugs, Wernicke’s encephalopathy. Laboratory Studies in Acute Confusional States: 1)Blood tests: Dr : anything you write is true - WBC: Meningi.s, encephali.s, sepsis. - PT and PTT: Hepa.c encephalopathy. - Arterial blood gas: Hepa.c encephalopathy, pulmonary encephalopathy, uremia, sepsis. - Sodium: Hyponatremia. - Serum urea nitrogen and crea.nine: Uremia - Glucose: Hyperglycemia, hypoglycemia. - Osmolality: Alcohol intoxica.on, hyperglycemia. - Liver func.on tests, ammonia: Hepa.c encephalopathy, Reye syndrome. - Thyroid func.on test: Hyperthyroidism, hypothyroidism. - Calcium: Hypercalcemia, hypocalcemia. - Drug screen: Drug intoxica.ons. - Cultures: Meningi.s, sepsis. - FTA or MHA-TP: Syphili.c meningi.s. - HIV an.body.ter: AIDS and related disorders. EEG : acute confusional status in temporal lobe epilepsy ECG & Echo : Ischemic Heart Dusease Dopler and US : 2) Urine, gastric aspirate: with Acute confusional state any pt. - Drug screen: Drug intoxica.on. Sample from -> -, blood - urine S Gastric - 3) Stool: - Occult blood: Hepa.c encephalopathy. 4) ECG: An.cholinergic or sympathomime.c intoxica.on (tachyarrhythmia), vascular disorders. 5) C.S.F: - WBC, RBC: Meningi.s, encephali.s, subarachnoid hemorrhage. - Gram's stain: Bacterial meningi.s. - AFB stain: Tuberculous meningi.s. - India ink stain: Cryptococcal meningi.s. - Cultures: Infec.ous meningi.s. - Cytology: Leptomeningeal metastases. - Glutamine: Hepa.c encephalopathy. - VDRL: Syphili.c meningi.s. - Cryptococcal an.gen: Cryptococcal meningi.s. - Polymerase chain reac.on: Bacterial meningi.s, tuberculous meningi.s, syphili.c meningi.s, Lyme disease, viral meningi.s and encephali.s, AIDS, leptomeningeal metastases. 6) CT brain scan or MRI: Cerebral infarc.on, intracranial hemorrhage, head trauma, toxoplasmosis, herpes simplex encephali.s, subarachnoid hemorrhage, intracranial tumor. 7) EEG: Complex par.al seizures (epilep.form discharge over temporal or frontal lobes), herpes simplex encephali.s (periodic triphasic complexes over temporal or frontal lobes), hepa.c encephalopathy (generalized triphasic waves), nonconvulsive seizures (epilep.c discharges).  Treatment of Acute confusion This done by iden.fying the primary cause & correct it.  Coma & Stupor ‫ اﯾﺎم وھﻜﺬا‬١٠ ‫ ﺳﺎﻋﺔ او‬١٢ ‫ اﻧﻤﺎ ارﺑﻊ ﺳﺎﻋﺎت او‬،‫ﻣﻮ دﻗﯿﻘﺔ دﻗﯿﻘﺘﯿﻦ‬ Coma: It is a sleep like condi.on characterized by prolong loss of consciousness from which the pa.ent can not be aroused by vigorous s.muli. ،‫ ﻗﺪ ﯾﺴﻮي رﺳﺒﻮﻧﺲ )ﺣﺮﻛﺔ( ﻟﻜﻦ ﻣﯿﻜﻌﺪ ﯾﻔﺘﺢ ﻋﯿﻨﮫ وﯾﺴﻤﻌﻚ‬،‫اﺑﻮ اﻟﻜﻮﻣﺎ ﻟﻤﺎ ﺗﺴﻮﯾﻠﮫ ﺑﯿﻨﻔﻞ ﺳﺘﯿﻤﻮﻟﻲ‬ ‫اذا ﻛﻌﺪ وﺳﻤﻌﻚ ھﻨﺎ ﺳﺘﻮﺑﺮ‬ Stupor: It is a sleep like state characterized by prolong loss of consciousness from which the pa.ent can be par.ally aroused for transient period of.me by vigorous s.muli. It represent a less degree of disturb consciousness than coma.  Outline of causes of Coma B , it is due to disturbances in general metabolism, not due to Structural 1) Metabolic: defect >> so there is no focal neurological signs and no neck stiffness - - Drug overdosage (including alcohol) - Hypoglycaemia - D.M - Renal failure - Hepa.c failure - Hypothermia - Hypothyroidism - Cardiorespiratory failure - Hypoxic encephalopathy  2) Structural: a. DiPuse: - Meningi.s - Encephali.s Herpes simplex occurs in frontal and temporal mainly (‫ )ﯾﺘﺮﻛﺰ ھﻨﺎ‬but affect other areas as well - Other infec.ons (e.g. cerebral malaria) * - Subarachnoid hemorrhage - Epilepsy "Generalized" focal" "not - Head injury- in shuttering severcase - cause in israin, ‫ ﺣﺘﻰ ﻟﻤﺎ ﺗﺴﻮﯾﻠﮫ‬،‫ او اﻛﺜﺮ ﻣﻨﮫ اﻧﮕﺺ‬٪٧٠ ‫ﺑﺤﯿﺚ اﻟﮭﻤﺴﻔﯿﺮ‬ ‫ ﻣﻮ داﺋﻤﺎ ﯾﺒﯿﻦ‬MRI - Hypertensive encephalopathy Rare, because when you correct BP, Return to normal should it b. Focal: or inant - mid cranial Rossa * Supratentorial lesions: - Cerebral hemorrhage CVA - Cerebral infarc.on with edema - Subdural hematoma - Extradural hematoma - Tumor - Cerebral abscess - Pituitary apoplexy  fossa Post-cranial - ‫ ﺑﺲ ﺑﺪل اﻟﺴﺮﺑﺮم ﺣﻂ ﺳﺮﻟﻢ او ﺑﺮﯾﻦ ﺳﺘﯿﻢ‬، ‫ ﻧﻔﺲ اﻟﺴﺎﺑﻘﺔ‬:‫د‬ * Subtentorial lesions: ‫ ووﺧﺮ اﻟﺒﺘﺘﺮي‬،‫راح ﺗﺼﯿﺮ اﻧﻔﺮا ﺗﻨﺘﻮرﯾﻞ‬ - Cerebellar hemorrhage - Pon.ne hemorrhage - Brainstem infarc.on - Tumor - Cerebellar abscess - Secondary eYects of transtentorial hernia.on of brain due to cerebral mass lesions e.g - Passa Tumor in was Art. enough big dust. Gossa or effect postcranial to cause  Emergehof Immediate Assessment of Coma: " * 7 ques.ons: it not open open it "tracheostomy is 1) Is the airway clear? Check blood gases to evaluate this issue. Intubate & give oxygen if there is airway compromisa.on. 2) Is the pa.ent =nng? EEG/blood glucose. Give I.V glucose, oxygen & diazepam. I Rocconor Battle sign 3) Are there sings of cranio-facial trauma? Any undouker -> any fr. we in Head/skull C.T scan & request neurosurgical opinion. the 4) Is the neck broken? - nate=> never sofstly perform exclude it by neck imaging stiffness, or let a experience cordingury/Death Risk of orthopedistparticipate Use X-ray to verify this issue. Splint neck if exist. haemaccel 5) Is there major hemorrhage? In the fluid only if little loss, blood or will be late if transf if sever blood needs blood "S loss, transf." in FP Maintain circula.on. because: 35 Emrally is. 5. im to notice s. = is et al there's Loss of Dee tendan Reflex coma 6) Is there evidence of D.M? => once ⑰ in cause. Permenant Damage -> Send for blood/urine glucose. Treat appropriately. Brain indicate prognosis which poor lead to visual loss 7) Is there evidence of drug overdose or misuse? Damage Paralysis.... and Brain or Deal or occurs, Check pupils/ven.la.on. Naloxone?  Basic Neurological Examina5on in Coma Assess level of consciousness (use Glasgow coma scale), Signs of head injury: local bruising (like raccoon eyes & BaMle sign), fractures & penetra.ng wounds, bleeding from nose or ears, Splint the neck: head injury may be associated with fracture of cervical spine, If no neck injury (clinically & X-ray) check for neck s.Yness, Check res.ng pupillary size, & pupillary responses to light, Ocular movements: spontaneous, following & to ‘doll’s head’ (should done if no voluntary response), Tell him to open his eyes, if not open, open it by your hand, if he see / moved his eye to inward this is psychological (hysterical), if not moved to inward, do dolls reflex, if eye doesn’t go away from the side of head ‫ﻻزم ﺗﺮوح ﻋﻜﺲ اﻻﺗﺠﺎه‬ ‫اذا ﺑﻘﺖ ﺛﺎﺑﺘﮫ وﯾﺔ ﺣﺮﻛﺔ اﻟﺮاس ﻓﮭﺬا ﻧﻐﺘﻒ‬ Limbs: posture, tone & movement, areraincoma absent Doll Reflex - a in rediatric and adults … ‫ ﻋﻨﺪه ﻛﺮاﺗﯿﺮﯾﺎ‬،‫ ﯾﻌﻨﻲ ﺑﺮﯾﻦ دﯾﺚ ﻻ ﯾﺸﺨﺺ ﻣﻦ اﻟﺪول رﻓﻠﻜﺲ‬،‫ﯾﻌﻨﻲ ﻣﻮ ﻛﻞ واﺣﺪ ﻓﻘﺪ اﻟﺪول ررﻓﻠﻜﺲ ﯾﻌﻨﻲ ﻋﻨﺪه ﺑﺮﯾﻦ دﯾﺚ‬ ReJexes & plantar responses, Fundi  Causes of Coma without Focal Neurological Signs, or Neck S89ness: Metabolic coma: - Hypoglycaemia - Hyperglycaemia - Liver failure - Renal failure - Respiratory failure with CO2 reten