Alteration of consciousness2

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<ul><li>1.Alteration of Consciousness</li></ul> <p>2. Reticular activating system(RAS) 3. </p> <ul><li>Good Consciousness =</li></ul> <ul><li>Alertness + Awareness</li></ul> <p>4. </p> <ul><li>Diminished alertness = </li></ul> <ul><li>Widespread abnormalities of cerebral hemispheres or reduced activity ofreticular activating system (RAS) </li></ul> <p>5. Definition of Terms </p> <ul><li>Confusion :</li></ul> <ul><li><ul><li>impaired attentionand concentration, manifestdisorientation in time, place and person , impersistent thinking, speech and performance, reduced comprehension and capacity to reason </li></ul></li></ul> <ul><li><ul><li>Fluctuate in severity, typically worse at night sundowning </li></ul></li></ul> <ul><li><ul><li>Perceptual disturbances and misinterpret voices, common objects and actions of other persons </li></ul></li></ul> <ul><li>Confusion is also found in dementia (progressive failure of language, memory, and other intellectual functions) </li></ul> <p>6. Definition of Terms </p> <ul><li>Delirium : confusion and associated agitation, hallucination, convulsion and tremor </li></ul> <ul><li>Amnesia : a loss of past memories and to an ability to form new ones, despite alert and normal attentiveness </li></ul> <p>7. Level of Consciousness(1) </p> <ul><li>Alert :normal awake and responsive state </li></ul> <ul><li>Drowsiness:state of apparent sleep, briefly arousal with oral command </li></ul> <ul><li>Lethargic : resembles sleepiness, but not becoming fully alert, slow verbal response and inattentive. Unable to adequately perform simple concentration task (such as counting 20 to 1) </li></ul> <p>8. Level of Consciousness (2) </p> <ul><li>Somnolent :easily aroused by voice or touch; awakens and follows commands; req uiredstim ulationto maintain arousal </li></ul> <ul><li>Obtunded/Stuporous : arousable only with repeated and painful stimulation; verbal output is unintelligible or nil; some purposeful movement to noxious stimulation </li></ul> <ul><li>Comatose:no arousal despite vigorous stim ulation , no purposeful movement- only posturing, brainstem reflexes often absent </li></ul> <p>9. Dementia VS Confusional state </p> <ul><li>Dementia </li></ul> <ul><li><ul><li>Longstanding nature </li></ul></li></ul> <ul><li><ul><li>Varies little from time to time </li></ul></li></ul> <ul><li><ul><li>Memory problem </li></ul></li></ul> <ul><li>Confusional state </li></ul> <ul><li><ul><li>Acute </li></ul></li></ul> <ul><li><ul><li>Fluctuate </li></ul></li></ul> <ul><li><ul><li>Clouding of consciousness </li></ul></li></ul> <p>10. Causes of confusional state(1) </p> <ul><li>Medical or surgical disease </li></ul> <ul><li>Metabolic disorders</li></ul> <ul><li><ul><li>Hepatic </li></ul></li></ul> <ul><li><ul><li>Uremic </li></ul></li></ul> <ul><li><ul><li>Hypo and hypernatremia </li></ul></li></ul> <ul><li><ul><li>Hypercalcemia </li></ul></li></ul> <ul><li><ul><li>Hypo and hyperglycemia </li></ul></li></ul> <ul><li><ul><li>Hypoxia </li></ul></li></ul> <ul><li><ul><li>Hypercapnia </li></ul></li></ul> <p>11. Causes of confusional state(2) </p> <ul><li>Infectious illness </li></ul> <ul><li><ul><li>Pneumonia </li></ul></li></ul> <ul><li><ul><li>Endocarditis </li></ul></li></ul> <ul><li><ul><li>Urinary tract infection </li></ul></li></ul> <ul><li><ul><li>Peritonitis </li></ul></li></ul> <ul><li>Congestive heart failure </li></ul> <ul><li>Postoperative and posttraumatic states </li></ul> <p>12. Causes of confusional state(3) </p> <ul><li>Drug intoxication </li></ul> <ul><li>Opiates </li></ul> <ul><li>Barbiturates </li></ul> <ul><li>Other sedatives </li></ul> <p>13. Causes of confusional state(4) </p> <ul><li>Diseases of nervous system </li></ul> <ul><li>Cerebrovascular disease, tumor, abscess </li></ul> <ul><li>Subdural hematoma </li></ul> <ul><li>Meningitis </li></ul> <ul><li>Encephalitis </li></ul> <ul><li>Cerebral vasculitis </li></ul> <ul><li>Hypertensive encephalopathy </li></ul> <p>14. Approach </p> <ul><li>History--- emphasizing the patients condition before the onset of confusion </li></ul> <ul><li>Clinical examination--- focus on</li></ul> <ul><li><ul><li>signs of diminished attentiveness, disorientation, and drowsiness and</li></ul></li></ul> <ul><li><ul><li>the presence of localizing neurological signs </li></ul></li></ul> <p>15. Aim of care in confusion patients </p> <ul><li>Control underlying medical illness </li></ul> <ul><li>Quiet the patient and protect him from injury </li></ul> <ul><li>Discontinue drugs that could possibly be responsible for the acute confusional state : sedating, antianxiety, narcotic, anticholinergic, antispasticity, corticosteroid, L-dopa, metoclopramide, cimetidine, antidepressant, antiarrhythmic,anticonvulsant, antibiotics. </li></ul> <p>16. Medical management </p> <ul><li>Haloperidol, quetiapine, risperidone are helpful in calming the agitated and hallucinating patient, but should be used in the lowest effective doses </li></ul> <ul><li>In alcohol or sedative withdrawalchlordiazepoxide is the drug of choice. Chloral hydrate, lorazepam, and diazepam are equally effective </li></ul> <p>17. COMA 18. GLASGOW COMA SCORE </p> <ul><li>Eye opening: </li></ul> <ul><li>Nil 1 </li></ul> <ul><li>To pain (applied to limbs) 2 </li></ul> <ul><li>To voice (including command) 3 </li></ul> <ul><li>Spontaneous (withblinking ) 4 </li></ul> <ul><li>Motor response: </li></ul> <ul><li>Nil 1 </li></ul> <ul><li>Arm extension to pain (nail bed pressure) 2 </li></ul> <ul><li>Arm flexion to pain (nail bed pressure) 3 </li></ul> <ul><li>Arm withdrawal from pain(nail bed pressure)4 </li></ul> <ul><li>Hand localizes pain(supraorbital or chest pressure)5 </li></ul> <ul><li>Obeys commands 6 </li></ul> <ul><li>Verbalize response: </li></ul> <ul><li>NIL 1 </li></ul> <ul><li>Groans (no re-cognizable words) 2 </li></ul> <ul><li>Inappropriate words (including expletives) 3 </li></ul> <ul><li>Confused speech 4 Orientated 5 </li></ul> <p>19. Glasgow Coma Scale : Eye opening (E) 20. Glasgow Coma Scale : Motor response (M) 21. Glasgow Coma Scale : Verbal response (V) 22. </p> <ul><li>Notes </li></ul> <ul><li>scoring from the best response</li></ul> <ul><li>verbal response will not correct in the condition of aphasia, intubation andfacialinjury </li></ul> <ul><li>sensory loss may interfere painful stimulation</li></ul> <ul><li>eye opening may be interfered by orbital swelling and 3 rdCN palsy </li></ul> <ul><li>arm movements may be impaired from local trauma or cervical cord lesion</li></ul> <p>GLASGOW COMA SCORE 23. Approach to the patient </p> <ul><li>History </li></ul> <ul><li><ul><li>Circumstances and rapidity with which neurologic symptoms developed </li></ul></li></ul> <ul><li><ul><li>Immediately preceding medical and neurologic symptoms </li></ul></li></ul> <ul><li><ul><li>Use of medications, illicit drugs, or alcohol </li></ul></li></ul> <ul><li><ul><li>Chronic liver, kidney, lung, heart, or other medical disease </li></ul></li></ul> <p>24. General physical examination </p> <ul><li>Vital sign </li></ul> <ul><li><ul><li>Temperature </li></ul></li></ul> <ul><li><ul><li><ul><li>Fever </li></ul></li></ul></li></ul> <ul><li><ul><li><ul><li>Hypothermia --</li></ul></li></ul></li></ul>