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Altered Consciousness (3% of referrals to ER) Definitions Differential diagnosis Assessment - evaluation Management.

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Presentation on theme: "Altered Consciousness (3% of referrals to ER) Definitions Differential diagnosis Assessment - evaluation Management."— Presentation transcript:

1 Altered Consciousness (3% of referrals to ER) Definitions Differential diagnosis Assessment - evaluation Management

2 Reticular Activating System Sensorium Motor Response Unconsciousness: Loss of wakefulness other than sleep Bi-hemispheral dysfunction (awareness* + wakefulness) or RAS dysfunction (wakefulness) Injury and recovery patterns: Injury Fore>mid>hindbrain Recovery Hind>mid>forebrain *Awareness: cortical cognitive function

3 Clinical Assessment of Unconsciousness Definitions and Commonly Used Jargon Full Consciousness Wakefulness Awareness Somnolence – drowsiness Altered consciousness (Encephalopathy) Stupor Semi-coma Coma Altered intellectual functioning and behavior Confusional state Delirium [acute cognitive dysfunction] Agitation Psychosis Vegetative state + Wakefulness - Awareness Syncope Short, transient loss of consciousness with loss of postural tone Near-syncope- premonition of syncope without loss of consciousness

4 Syncope Short, transient loss of consciousness with loss of postural tone Causes Transient reduction in CBF Vaso-vagal syncope: carotid, valsalva, micturation, tussive Neuro-cardiogentic syncope: prolonged standing, fright (tilt-test +) Orthostatic hypotension Dehydration, drugs, neuropathy, etc. Arrhythmia Tachy-arrhythmia (VF, VT, torsad, SVT in patients with pre-excitation) Brady-arrhythmia (Adams Stocks – AVB) Valvular disease (Aortic stenosis, HOCM) PE TIA – transient ischemic attack Seizures* (epilepsy) * Short clonus & loss of urinary sphincter control do not indicate epilepsy

5 Syncope Evaluation in ER and on follow up Medical history: True syncope vs. “faintness”, dizziness, blurred vision, etc. Routine: previous episodes, precipitating factor(s), other illness, Medications Eye witness: setup, sequence of events, pallor, cyanosis, sweating seizure, initial vital signs (pulse), gaze direction PE: Routine, particularly cardiovascular and neurological, orthostatism evidence for trauma, tongue, loss of sphincter control Further evaluation: ECG >>> monitoring >>>holter 24h>>>holter 72h>>>loop recorder Cardiac echo EEG Carotid sensitivity, tilt test Other important factors in likelihood assessment: age, gender Family history of SD

6 Glasgow Coma Scale Assessing the Degree of Unconsciousness

7 Glasgow Coma Scale Eyes Opening 4 - spontaneous, to speech 3 - to loud noise 2 - to pain 1 - none Motor Response 6 – obeys orders 5 – directed to pain 4 – not directed to pain 3 – decortication response to pain 2 – decerabration response to pain 1 - none Verbal Response 5 – spontaneous, relevant 4 – confusional, disoriented 3 – clear but meaningless 2 – non articulated sounds 1 - none Maximum – 15 Minimum – 3 7> Coma Used by Trauma and Neurosurgery disciplines to assess prognosis… … but is meaningless in that respect in non-trauma causes

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9 Altered Consciousness Differential Diagnosis Anatomical vs. metabolic causes Mixed / combined head trauma during driving “under the influence” One leads to the other metabolic encephalopathy >> brain edema>>altered CBF

10 Altered Consciousness Causes (1) Altered anatomy Trauma (concussion/comotio cerebri<

11 CVA types Ischemic – arterial thrombosis Atherosclerosis, atheroembolic Thrombembolic (RHD, A. Fib, paradoxical) Vasculitis Thrombophyllia (anticardiolipin, hyperhomocysteinemia, etc.) Hyperviscosity (leukemia, thrombocythemia, PP, etc.) Air embolus, decompression injury Venous thrombosis Thrombophilia, vasculitis, hyperviscosity etc. Hemorrhagic CVA Intra-parenchymal hemorrhage (primary / transformation) Subarachnoid hemorrhage Other intracranial hemorrhage Epidural hemorrhage Subdural hemorrhage

12 Subarachnoid Hemorrhage Bleeding Berry aneurism Within circle of Willis Association with PCKD etc. Trauma brain lacerations Hemorrhagic CVA complicated by intraventricular hemorrhage Subarachnoid hemorrhage leads to cerebral vascular vasoconstriction !! >>>subsequent hypoxic damage!! Headache Meningeal irritation

13 Epidural Hematoma Arterial bleeding (from MMA), often associated with fracture of parietal bone Commotio cerebri>> short lucid interval>> rapid and dramatic evolution herniation

14 Subdural Hematoma Venous bleeding from veins in subdural space, near attachment to sinuses caused during “minor” head concussion, particularly in babies and elder patients Slow insidious presentation (Particularly in the aged: unnoticed trauma, extra-space)

15 Altered Consciousness Causes (1) Altered anatomy Trauma: CVA: Tumor: Primary / metastatic Loss of BBB and edema Brain edema (increased ICP, altered CBF, herniation) “closed box phenomenon”

16 Glioblastoma tumor Vasogenic edema Mass effect Herniation Roramen magnum Trans-tentorial etc. Altered consciousness

17 Brain Edema Final Common Pathway Infection (meningitis, encephalitis Abscess, Rey) hypoxia-induced Brain damage Altered CSF drainage Tumor Primary/metastatic Brain Edema ↑ ICP ↓CBF →herniation Severe HTN Drugs, toxins Trauma Hemorrhage Acute hyponatremia High internal osmolytes

18 Altered Consciousness Causes (2) Altered Blood Supply Syncope Severe shock Lethal arrhythmia CVA Increased ICP (elder patients tolerate it better d/t brain atrophy) Altered brain oxygenation Altered blood supply Hypoxia CO intoxication Methemoglobinemia Cyanide poisoning (mitochondrial Anoxia)

19 Altered Consciousness Causes (3) CNS Infection Meningitis Enchephalitis Brain abscess Meningococcemia

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21 Measles

22 AIDS

23 Altered Consciousness Causes (3) Electrical disorder (seizure) Primary (epilepsy: primary vs. secondary) Secondary to any other acute CNS disorder

24 Altered Consciousness Causes (4) Metabolic causes Hypoxia Hypercarbia (acidosis, brain edema, hypoxia) Hyperglycemia Hypoglycemia Altered osmolality: ↑↓ Na Other electrolyte disorders ↑↓ Ca, Mg ↑ K ↓ P Acid-base anomalies Severe metabolic & respiratory acidosis Severe metabolic & respiratory alkalosis

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26 Altered Consciousness Causes (5) Metabolic causes (cont.) Hepatic failure (hepatic encephalopathy) Renal failure (uremic encephalopathy) Endocrinopathy Hypothyroidism (myxedema coma) Addison crisis Pan-hypopituitarism Altered core temperature Hypothermia Hyperthermia Sepsis (multifactorial) Deficiency states thiamine, B 6 and others Acute intermittent porphyria

27 Hepatic Encephalopathy: Clinical Stages Personality changes Flapping tremor Combative (“stupor”) coma

28 Myxedema coma

29 Altered Consciousness Causes (6) Intoxications and medicationsToxidromes Alcohols Ethanol*, methanol, isopropyl alcohol, ethylene glycol Odor, determination of levels, osmolar gap, acid-base status, kidney function, urinary oxalates, optic disc Sympatholytics Barbiturates* narcotics, hypnosedatives, benzodiazepines Flunitrazepam (hypnodorm) Respiratory depression, bradycardia, myosis, toxic screen Sympathomimetics Amphetamines, cocaine Sympathetic overactivity, tachycardia, hyperthermia, high BP, mydriasis, convulsions, toxic screen

30 Altered Consciousness Causes (7) Intoxications and medications (cont) Anticholinergics, anti-histamines Phenothiazines, butirofenons, atropine* containing drugs and herbal extracts Dry skin, tachycardia, dysrrhythmias, extrapyramidal disorder, toxic screen Cholinergic Organic phosphates, carbamate Muscarinic and nicotinic overactivity: sweating, salivation, tearing, diarrhea, bronchorrhea & wheezes, myosis, bradycardia,fasciculations, convulsions Serotonin syndrome TCA, SSRI, SNRI, Lithium Dry skin, hyperthermia, diaphoresis, tachycardia, muscle rigidity, myoclonus, Hyper-reflexia, seizures, tremor, ataxia, toxic screen

31 Altered Consciousness Causes (8) Intoxications and medications (cont) Miscellaneous Lithium, bromides, salycilates, iron, digitalis, Inhalants (Freon, glue sniffing) Gamma-hydroxybutirate (GHB) Hallucinogens LSD, NMDA (ecstasy), Phencyclidine (PCP), marijuana, mushrooms Mydriasis (not PCP), nystagmus (PCP),dysrhythmias, seizures, hyperthermia, Toxic screen

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34 Altered Consciousness Causes (9) Withdrawal Wernicke’s encephalopathy Psychogenic Catatonia Conversion disorder Butterfly eyes Evidence for hyperventilation Limb tonus

35 Epilepsy Focal seizure: any focal type or “Jacksonian March” Generalized seizure: Grand mal - Tonus >>>clonus phases Petit mal Electrical disorder: Primary Secondary: chronic or acute (reflecting major disorders) i.e. seizure does not imply primary electrical disorder!! Status Epilepticus: May induce subsequent anoxic encephalopathy Neural exitoxicity Post-ictal state: Delirium, amnesia Todd’s paralysis

36 Altered Consciousness Assessment (1) Life-threatening condition! ABC first! Evaluation in parallel with treatment Neurological examination – last step of PE גם כינים וגם פשפשים Medical History Eye witness / collateral anamnesis Patient’s surroundings Epidemiology (single / multiple cases) Pre-existing illnesses, medications Other available medications (used by family members) Ethylism, Drug abuse Prior trauma Preceding headache, fever, convulsions Description of episode, sequence of events Look back for evidence at the area of interest

37 Altered Consciousness Assessment (2) Physical examination Vital signs: HR (may reflect direct cause or secondary effects such as ↑ICP) BP (may reflect direct cause or secondary effects such as ↑ICP) Temperature (use of hypothermic thermometer when indicated) Breathing rate and pattern (Cusmaul, Chain Stocks, cluster, atactic) Full medical examination: Look for: trauma signs, needle pricks, purpura, nuchal rigidity Bracelets/indicators of insulin TX, epilepsy, Immunosupression, anaphylaxis

38 Spotted fever

39 Altered Consciousness Assessment (3) Neurological examination GCS Eyes: Gaze: nystagmus, doll’s eye, direction stroke – towards lesion seizure – away from lesion Pupils: equal / unequal, reactive / non-reactive, size Unequal, structural lesion, herniation, R/O eye drops for glaucoma Pinpoint: MO, pontine hemorrhage Small: organic phosphor, barbiturates Dilated: anticholinergic (including atropine and plants), antihistamines, antidepressants and other serotoninergic, anoxic brain damage Fundus: increased ICP – papiledema, venodilation, loss of venous pulsation

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41 Altered Consciousness Assessment (3) Neurological examination GCS Eyes: Gaze: nystagmus, doll’s eye, direction stroke – towards lesion seizure – away from lesion Pupils: equal / unequal, reactive / non-reactive, size Unequal, structural lesion, herniation, R/O eye drops for glaucoma Pinpoint: MO, pontine hemorrhage Small: organic phosphor, barbiturates Dilated: anticholinergic (including atropine and plants), antihistamines, antidepressants and other serotoninergic, anoxic brain damage Fundus: increased ICP – papiledema, venodilation, loss of venous pulsation

42 Altered Consciousness Assessment (4) Neurological examination (cont) Posture and muscle tone Localizing findings: Cranial motor nerves Lateralization of motor deficits Pyramidal signs Frontal signs Repeated neurological examination, again and again Look for dynamics

43 Neurological re-assessment

44 Altered consciousness Management (1) Life-threatening condition! ABC first! Evaluation in parallel with treatment Continue ABC Airway protection (intubation) Oxygen Venous excess, glucometer Blood and urine samplings: CBC, SMAC, blood gases, INR osmolality, toxicology screen, carboxyhemoglobin, etc. ECG (hints for cause) CXR (non-cardiogenic PE, aspiration and other anomalies) Eye protection

45 Altered consciousness Management (2) Diagnostic / therapeutic interventions Thiamine 100 mg Glucose 25-50% 50 ml Naloxone (narcan) 0.1 >>> 0.8 mg beware, after tube, go low and slow: acute withdrawal Flumazenile (anexate) mg Complementary evaluation Blood and urine sampling (TSH, porphyrines etc.) Cultures Urinalysis CT LP EEG

46 Altered consciousness Management (3) Subsequent measures, related to progress in evaluation Correction of metabolic abnormalities Decontamination (NGT, activated charcoal) Specific treatment for identified disorders Thrombolysis, surgical TX, medications, dialysis etc. Monitoring Supportive care Repeated assessment If no cause remains unidentified – repeated evaluation of history and surroundings, interview of delivering paramedics, involving the police etc. Brain Rescue ICP monitoring, hyperventilation, hypothermia, reducing metabolic activity, Ca ++ blockers EPO, PARPP inhibitors, antioxidants etc. All experimental!!

47 Seizures Management ABC IV line / medications Benzodiazepines (diazepam, lorazepam, midazolam) Phenytoin Carbamazepine Valproate Magnesium sulphate Phenobarbital + (neuromuscular block) Medical history: if no known epilepsy consider wide spectrum of conditions, structural, metabolic, intox. etc. Look for initiating factor PE: Lab: If known epilepsy – drug levels. If not – CBC, wide biochemistry, blood gases, carboxyhemoglobin, tox. screen etc. Consider: CNS imaging and EEG

48 Take-Home Massages ABC first Collateral anamnesis from eye witnesses Keep on collecting relevant information – detective work Don’t jump to haste conclusions. Consider DDs “CVA” reflects locus minoris resistenti to metabolic derangement Make sure before labeling HY “Flees and mites” encephalopathy + trauma: drivers, alcoholics, metabolic disorders Hypoxic encephalopathy – final common pathway GCS is insignificant regarding prognosis in not-trauma cases In any diabetic patient – treat as hypo Syncope – recumbent position, raise feet


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