acute coma. unconsciousness, disturbance of consciousness degression of level of consciousness ...
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Acute coma
Unconsciousness , Disturbance of con
sciousness
Degression of level of consciousness
Deep inhibitory state of higher nervo
us activity
DefinitionDefinition
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
Composition of consciousness Cognition Contents : Orientation, Perceptivity, Attention, Remembranc
e, Affection, Thinking and Behavior
Expressed : Language,Body movement and behavior
Controlled : Cerebral cortex
Waking state
Controlled
Ascending reticular activating system in b
rainstem ( ARAS )
Function
Special sensory conduction →
Unspecial nerve corpuscle in thalamus →
All cerebral cortex
Etiology and pathology
Disturbance
① Cerebral cortex
② Ascending reticular activating sys
tem in brainstem or thalamus
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
Disturbance of consciousness in level
Coma, Confusion
Special kinds of disturbance of consciousne
ss
Dementia, lapsus memoriae
Clinical classificatioClinical classificationn
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
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
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
Special groups of conscious disturbance
— coma vigil
1) Open and close eyes
2) Chew and swallow
3) Sleep-wake cycles
Decorticate syndrome
1) Arms flex , leg straighten
2) Higher muscular tension
3) Babinski sign
4) Cerebral cortex is damaged
Decerebrate syndrom 1) Four limbs straighten
2) Higher muscular tension
3) Babinski sign
4) All brain is damaged
Akinetic mutism
1) Muscle relaxation ,
2) No babinski sign
3) Ascending reticular activating system in brainstem or thalamus is damaged
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
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.
Brain death
Complete and irreversible cessation of brain
activity (cerebral, brain stem , cerebellum)
Criteria
1) Deep coma
2) No spontaneous respiration
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
Hysteria
Syncope
1. Transient loss of consciousness and posture
2. A global reduction in blood flow to the brain
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
Abulia
A lesion of both lobus frontalis
Serious Apathy
Stuporous state
Stupor syndrom
A rough response ( like screaming ) to a
noxious stimulus
Etiology Central nervous system diseases
Cerebrovascular disease Cerebral thrombosis Cerebral embolism Cerebral hemorrhage Subarachnoid hemorrhage
Headtrauma
Seizure
Inflammation
Encephalitis, meningitis, cerebral abscess
Tumor
Hypoxia Heart -- Cardiac output ↓
Heart failure, Asystole, tachycardia, br
adycardia
Lung -- pO2 ↓, pCO2↑, acidosis
COPD, pneumonia, pneumonedma pul
monary infarction, drowing
Liver--hepatic coma
Serious hepatitis,hepatonecrosis
hepatic cirrhosis
Kidney—Uremia
Acidosis, ion disturbance or cerebral edema af
ter dialysis
Metabolic abnormalities Hypoglycemia, hyperglycemia,Ketoacidosis, hyperosmosis , lactic acidosis hyperthyroidism crisis , Addison‘s diseasesheehan syndrome
Electrolyte disturbances
Low sodium, low chlorine, water intoxication
Intoxication
Drug :
Benzodiazepine, barbiturates, anti
psychotic drug
Insecticide : Organophosphorus , pyrethroid
carbamate pesticide , weed killer
Other intoxicant
Alcohol, Carbon Monoxide, Orga
nic solvent, poisnous vapor
Physical examination
General examinationGeneral examination TemperatureTemperature
T↑ : Inflamation, central high fever
heat stroke
T↓ : Shock, hypoglycaemia, Hypnotic intoxication
Arterial pulse
p ↓ : Sinus bradycardia, atrial ventricul
ar block(A-VB) ,intracranial hypertension
p↑ : Hyperpyrexia, hyperthyreosis conge
stive heart failure, shock supraventricular tach
ycardia
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
Blood pressure
BP↑ : hypertensive encephalopathy, CH
BP↓ : shock
Skin and membrana mucosa
Jaundice, bleeding point, ecchymosis,
Sweat, cyanosis, flush
Cranal trauma
Raccon eyes, Battlesign ,leakage of cerebrospinal fluid
Meningeal irritation sign
Kernig sign or brudzinski sign
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
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
Eye ground
Bleeding
Vitreous hemorrhage
Angiosclerosis,
Papilledema
Pain recationLocating
Decorticate rigidity ( thalamus or cerebral
hemisphere ),
Decerebrate rigidity (midbrain)
Assessment Degree of coma
Palsy sign
Hemiplegia, Babinski sign
Brainstem function
Corneal reflex
Oculovestibular reflex
Oculocephalic reflex (Dull head test)
Auxiliary examination
• CT, MRI , EEG , examination of cerebr
ospinal fluid
• Po2, Pco2, HCO3, BE , CoHb, Hemiglob
in, Choline esterase (CHE)
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
Diagnosis
History+Physical sign + Auxiliary examination
Onset : environment, process, time degree of urgency, motivation, etc.
Main symptom and concomitant symptom
Age, season, past history
Treatment Symptomatic treatment
1) Monitor: ECG, BP, Consciousness, pupil
pulse, pulse, respiration , etc.
2) Open respiratory tract
3) Balance water , electrolytes and acid-base.
4) Relieve and prevent cerebral edema
20% manital, complexglycerine, furose
mide , 50%Glucose, Albumin, etc.
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℃
Etiological treatment
Prevent complication
Aspirated pneumonia,
Urinary system infection,
Bedsore,
Disturbance of Water-Electrolyte ( Hyponatremi
a )
Acid- base balance
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