acute coma. unconsciousness, disturbance of consciousness degression of level of consciousness ...
TRANSCRIPT
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Acute coma
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Unconsciousness , Disturbance of con
sciousness
Degression of level of consciousness
Deep inhibitory state of higher nervo
us activity
DefinitionDefinition
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Mechanism
Consciousness ① Level of awareness of brain
② Sensation, Perception
Himself , Enviroment
③ Responsiveness
Inner need, External stimulation
④ Expressed
language, Body movement, Behavior
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Composition of consciousness Cognition Contents : Orientation, Perceptivity, Attention, Remembranc
e, Affection, Thinking and Behavior
Expressed : Language,Body movement and behavior
Controlled : Cerebral cortex
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Waking state
Controlled
Ascending reticular activating system in b
rainstem ( ARAS )
Function
Special sensory conduction →
Unspecial nerve corpuscle in thalamus →
All cerebral cortex
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Etiology and pathology
Disturbance
① Cerebral cortex
② Ascending reticular activating sys
tem in brainstem or thalamus
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Feature of Ascending reticular activating system
① Thin nerve fiber
② Longer transmiting distance
③ More times for neurone to be exchange
④ Influenced easily by enviroment and drug
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Disturbance of consciousness in level
Coma, Confusion
Special kinds of disturbance of consciousne
ss
Dementia, lapsus memoriae
Clinical classificatioClinical classificationn
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Somnolence Stupor Light coma Deep coma
Arousal + + - -
Orientation + - - -Go with examination + - - -
Reaction to stimuli + + + -
Spontaneous action + + + -
Brainstem reflexes + + +- -
Babinski sign + + +- -
Vital sign stable Stable stable unstable
Clinical classification of unconsciousness
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Confusion Confusion DeliriumDelirium
Somnolence + +
IrritationIrritation -- ++
Orientation + -
AttenuationAttenuation -- --
Delusion + +
IllusionIllusion +-+- ++
Insight + -
Change in Change in autonomic nerveautonomic nerve
++ ++
Special group of disturbance of consciousnessSpecial group of disturbance of consciousness
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Glassgow coma scaleEye Verbal Motor Scores
Obeys commands 6
Orientated Localises pain 5
Eyes openingspontaneously confused
Withdraws from pain 4
Eye opening tospeech
Inappropriate words
Flexion to pain (Decorticate) 3
Eye opening to pain
Incomprehe-nsible sounds
Extension to pain (Decerebrate) 2
No eye openingNo verbal
responseNo motor
response 1
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Special groups of conscious disturbance
— coma vigil
1) Open and close eyes
2) Chew and swallow
3) Sleep-wake cycles
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Decorticate syndrome
1) Arms flex , leg straighten
2) Higher muscular tension
3) Babinski sign
4) Cerebral cortex is damaged
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Decerebrate syndrom 1) Four limbs straighten
2) Higher muscular tension
3) Babinski sign
4) All brain is damaged
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Akinetic mutism
1) Muscle relaxation ,
2) No babinski sign
3) Ascending reticular activating system in brainstem or thalamus is damaged
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Differential diagnosis
Persistent vegetative state
1) “Unconscious and unaware”
2) Exhibit sleep-wake cycles
3) Grinding teeth, swallowing, smiling, shedding tears, grunting, moaning, or screaming
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4) Heads and eyes can track moving objects or
turn towards a sound
5) An impaired connectivity between the
brainstem, thalamus and the cortex
6) The general brain activity in the cortex is
lower in the PVS state.
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Brain death
Complete and irreversible cessation of brain
activity (cerebral, brain stem , cerebellum)
Criteria
1) Deep coma
2) No spontaneous respiration
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3) No response to pain, no cranial nerve reflexe
s
4) Spinal reflex may persist
5) EEG: flat or isoelectric 24h
6) Exclude for intoxication, hypothermia, meta
bolic disturbance or persistent vegetative st
ate
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Hysteria
Syncope
1. Transient loss of consciousness and posture
2. A global reduction in blood flow to the brain
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Locked-in syndrome
A lesion of the ventral pons..
1) Alert
2) Unable to response with speech or facial or li
mb movements
3) Vertical eye movements and blinking
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Abulia
A lesion of both lobus frontalis
Serious Apathy
Stuporous state
Stupor syndrom
A rough response ( like screaming ) to a
noxious stimulus
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Etiology Central nervous system diseases
Cerebrovascular disease Cerebral thrombosis Cerebral embolism Cerebral hemorrhage Subarachnoid hemorrhage
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Headtrauma
Seizure
Inflammation
Encephalitis, meningitis, cerebral abscess
Tumor
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Hypoxia Heart -- Cardiac output ↓
Heart failure, Asystole, tachycardia, br
adycardia
Lung -- pO2 ↓, pCO2↑, acidosis
COPD, pneumonia, pneumonedma pul
monary infarction, drowing
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Liver--hepatic coma
Serious hepatitis,hepatonecrosis
hepatic cirrhosis
Kidney—Uremia
Acidosis, ion disturbance or cerebral edema af
ter dialysis
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Metabolic abnormalities Hypoglycemia, hyperglycemia,Ketoacidosis, hyperosmosis , lactic acidosis hyperthyroidism crisis , Addison‘s diseasesheehan syndrome
Electrolyte disturbances
Low sodium, low chlorine, water intoxication
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Intoxication
Drug :
Benzodiazepine, barbiturates, anti
psychotic drug
Insecticide : Organophosphorus , pyrethroid
carbamate pesticide , weed killer
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Other intoxicant
Alcohol, Carbon Monoxide, Orga
nic solvent, poisnous vapor
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Physical examination
General examinationGeneral examination TemperatureTemperature
T↑ : Inflamation, central high fever
heat stroke
T↓ : Shock, hypoglycaemia, Hypnotic intoxication
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Arterial pulse
p ↓ : Sinus bradycardia, atrial ventricul
ar block(A-VB) ,intracranial hypertension
p↑ : Hyperpyrexia, hyperthyreosis conge
stive heart failure, shock supraventricular tach
ycardia
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Breath Rhythm Rhythm Cheyne-Stokes breathing
---- A lesion of Cerebral hemishere Central neuro-hyperventilation
---- A lesion of midbrain Ataxia breathing
---- A lesion of bulbus medullae
Smell
---- Rotten apple, garlic, alcohol, amonia, hepatic odor
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Blood pressure
BP↑ : hypertensive encephalopathy, CH
BP↓ : shock
Skin and membrana mucosa
Jaundice, bleeding point, ecchymosis,
Sweat, cyanosis, flush
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Cranal trauma
Raccon eyes, Battlesign ,leakage of cerebrospinal fluid
Meningeal irritation sign
Kernig sign or brudzinski sign
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Examination in internal medicine Heart, lung, liver, kidney, etc.
Neurologic check Eyes sign Pupil
One dilatation : Cerebral hernia
Both dilatation : Atropine poisoning Both diminution: Organophosphate , morphine
Hypnotic , hypoglycaemia A lesion of brainstem
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Eyeball position
FixationFixation ::Divergence: cerebellumDivergence: cerebellum
Side-glanceSide-glance ::
Lesion of Lesion of side glance centreside glance centre ( ( cerebcerebral hemisphere or pons ral hemisphere or pons ) )
Fasciculus longitudinalis medialiFasciculus longitudinalis mediali
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Eye ground
Bleeding
Vitreous hemorrhage
Angiosclerosis,
Papilledema
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Pain recationLocating
Decorticate rigidity ( thalamus or cerebral
hemisphere ),
Decerebrate rigidity (midbrain)
Assessment Degree of coma
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Palsy sign
Hemiplegia, Babinski sign
Brainstem function
Corneal reflex
Oculovestibular reflex
Oculocephalic reflex (Dull head test)
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Auxiliary examination
• CT, MRI , EEG , examination of cerebr
ospinal fluid
• Po2, Pco2, HCO3, BE , CoHb, Hemiglob
in, Choline esterase (CHE)
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GPT,GPT,GOT, GOT, Blood ammonia , BUN Cr, Blood ammonia , BUN Cr,
Ion, Blood glucoseIon, Blood glucose Detecting intoxicant or productDetecting intoxicant or product of of
metabolismmetabolism
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Diagnosis
History+Physical sign + Auxiliary examination
Onset : environment, process, time degree of urgency, motivation, etc.
Main symptom and concomitant symptom
Age, season, past history
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Treatment Symptomatic treatment
1) Monitor: ECG, BP, Consciousness, pupil
pulse, pulse, respiration , etc.
2) Open respiratory tract
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3) Balance water , electrolytes and acid-base.
4) Relieve and prevent cerebral edema
20% manital, complexglycerine, furose
mide , 50%Glucose, Albumin, etc.
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5) Protection for cerebral function
Radical scavenger : barbiturate, VC,VE Opiate receptor blocking pharmacon: Narcon Ca2+ receptor blocking pharmacon Nimodipi
ne , Flunarizine , etc.
6) Hypothermy, Hibernotherapy:
Tympanic temperature: 33~35℃
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Etiological treatment
Prevent complication
Aspirated pneumonia,
Urinary system infection,
Bedsore,
Disturbance of Water-Electrolyte ( Hyponatremi
a )
Acid- base balance