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Consciousness State of wakefulness with awareness of self and surrounding. Confusion Altered consciousness (the subject misinterprets his surrounding).

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Presentation on theme: "Consciousness State of wakefulness with awareness of self and surrounding. Confusion Altered consciousness (the subject misinterprets his surrounding)."— Presentation transcript:

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2 Consciousness State of wakefulness with awareness of self and surrounding. Confusion Altered consciousness (the subject misinterprets his surrounding).

3 Delirium state of high arousal ( acute confusion ) There is confusion and visual hallucination. Stupor Is abnormal sleepy stat from which the subject can be aroused by repeated stimuli.

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5 Coma ( or unconsciousness ) Is a state in which a patient is totally unaware of both self and external surroundings. Coma is not a disease. It is a symptom of disease or a response to an event.

6 Pathophysiology: A reduction in neuronal function resulting from disruption of cerebral cortical or brain stem integrity.

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8 * Encephalopathy: hypoxia ischemia seizures and post ictal states * Infection: encephalitis meningitis septicemia * Pressure effects: cerebral edema hydrocephalus space occupying lesions

9 * Vascular: - hemorrhage : extradural, subdural, subarachnoid, intraventricullar - hypertensive encephalopathy * Diseases of other systems: - hepatic coma - uremic encephalopathy - respiratory failure with C02 narcosis * Endocrine: - adrenal insufficiency - DKA / hypoglycemia - hypothyroidism - hypopituitarism

10 * Exogenous intoxication: - sedatives - salicylates - heavy metals - carbon monoxide * Fluid and acid-base balance: - H20, Na, K, Mg and Ca imbalance * Trauma.

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12 History Infection: Fever, irritability, lethargy, poor feeding, rash, seizure. Metabolic: Hx of DM, hx of previous loss of consciousness, hepatomegaly, jaundice, oligurea, hypertension.

13 Poisoning : Ask about drugs in the family, tablets, and alcohol. Seizure: Past hx of seizure, neurocutaneous lesions, developmental delay, abnormal eye movement, focal neurological signs.

14 Trauma: Hx of road traffic accident, fall, bruising, hemorrhage, fractures. Raised intracranial pressure: Headache, vomiting, focal neurological signs: ataxia, squint. Papilloedema, retinal hemorrhage.

15 Physical Examination General Examination Neurological Examination

16 In General Examination : Vital Signs:- IRREGULAR – Cardiac diseases ABSENT – Peripheral emboli FEEBLE – Circulatory collapse PULSE BLOOD PRESSURE - CVA - hypertensive encephalopathy - Cardiogenic shock - Septicemia - Addisons disease

17 TEMPERATURE FEVER HYPOTHERMIA - Drugs : Barbiturate - Circulatory failure - Myxoedema - Systemic infection : malaria - Meningitis / encephalitis - Heat stroke

18 CYANOSIS JAUNDICE PURPURA SKIN RASH Skin and mucous membranes:-

19 Head - scalp :- fractures, hematomas,ant fontanels. ENT :- discharge, blood Fundoscopy Neck - Cx. Spine:- fracture, neck stiffness, carotid pulses

20 Neurological examination Determine level of consciousness by GCS

21 * The Glasgow Coma Scale is used to determine the severity of a brain injury. It is often used at the emergency scene or emergency room. * The scale is used as part of the initial evaluation of a patient, but does not assist in making the diagnosis the cause of coma * Motor, verbal, and eye responses are rated.

22 Spontaneous To loud voice To pain None Spontaneous To loud voice To pain None Eye Opening

23 smile, follows objects. spontaneous irritable cry Cries only to pain Moans to pain None Oriented disoriented and converses inappropriate words Incomprehensible sounds None Verbal Response

24 Obeys commands Localizes pain Withdraws from pain Abnormal flexion (decorticate posture) AbnormalExtension (decerebrate posture) None Obeys commands Localizes pain Withdraws from pain Abnormal flexion (decorticate posture) Abnormal Extension (decerebrate posture) None Motor Response

25 GCS Mild=13-15 Moderate=9-12 Severe=3-8 Minimum=3 - Maximum=15

26 Core Neurological Exam (for coma); 1)Respiratory rate 2)Pupil 3)Extra ocular muscle, function muscle 4)Motor exam 5)Ciliospinal reflexes

27 Supra-orbital nail-bed sternum METHODS OF ELICITING MOTOR RESPONSE MOTOR RESPONSE MOTOR RESPONSE

28 PUPILS – SIZE AND REACTION TO LIGHT Normal, reactive DIENCEPHALIC Small, reactive MIDBRAIN Large, fixed III NERVE (UNCAL) dilated, fixed PONS pinpoint METABOLIC

29 yes (brain stem intact) yes (brain stem intact) no (brain stem damage) no (brain stem damage)

30 Chyne-Stoke breathing (cerebral hemisphere lesion) - Chyne-Stoke breathing (cerebral hemisphere lesion) - Central Neurogenic Hyperventilation (midbrain) - Apneustic breathing (pons) - Ataxic breathing – gasping (medulla)

31 Drugs screen(eg_salicylates- -diazepam-narcotics-amphetamines) -Routine biochemistry (urea-electrolytes- glucose-calcium-liver biochemistry) -Metabolic and endocrine studies (TSH-serum cortisol) - Blood cultures such as cerebral malaria(thick blood film) -If the explanation remains unclear,further investigation are needed. INVESTIGATION

32 IMAGING CT or MRI brain imaging may indicate an otherwise unsuspected mass lesion or intracranial hemorrhage.

33 CSF examination Lumber puncture should be performed in coma only after careful risk assessment.it is usually contraindicated when an intracranial mass lesion is a possibility.CT is necessary to exclude this. CSF examination is likely to alter therapy only if undiagnosed meningoencephalitis or other identifiable infection is present.

34 lumbar puncture….

35 Electroencephalography EEG is of some value in the diagnosis of metabolic coma and encephalitis.

36 Management of comatose patient Immediate Therapy Specific Therapy

37 A A B B C C

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