Altered Mental Status and Coma by yurtgc548

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									Altered Mental Status and Coma


          Brian Nelson
Case No. 1
   A 21 yo BF presents to the Baltimore City
    Hospital E.D. in the summer of ‘78.
   Her family states she is having a bad
    headache and needs her “Quiet World”
    tablets
Case continues
   No history other than an Ambulance took
    her to another hospital earlier that day when
    a neighbor heard her screaming and called
    EMS
   At the other hospital an exam and CBC
    were said to be normal and she was
    discharged
General Exam
   Patient grossly delirious, oriented to name
    only
   BP 125/70, P 76, RR 24, T 100.2 orally
   HEENT: PERRL, fundi difficult to evauate
    because of roaming eyes, grossly normal
   Neck: Very Stiff
   Chest: Loud wet rales throughout lung
    fields
Neurologic Exam
   Able to follow only simplest comands,
    Cranial Nerves grossly intact, Cerebellar
    could not be tested, specific muslce group
    strength could not be tested, but patient
    moved all extremities and fought attempts
    to test range of motion. Reflexes, gait and
    Romberg could not be tested
Diagnostic workup
   CXR: Complete opacification of left lung
   CBC: Hct 43, WBC 10.7 K, 75 segs, 17
    bands, 7 lymphs
   ABGs on room air: 7.42/37/98
   Lytes, BUN, glucose, Ca, PO4 all normal

   Provisional Diagnosis?
Diagnosis and Dilemma
   Provisonal Diagnosis: Pneumococcal
    Pneumonia with secondary meningitis

   Plan? Allow that in 1978 the nearest CT
    scanner was 5 miles away (and slow first
    generation). Minimum time to get a head
    CT 3 hours
LP was performed
   Opening pressure was 28 cm H2O

   5 cc clear spinal fluid removed

   5 minutes later the patient lost
    consciousness, dilated her left pupil and
    stopped breathing
Coma mnemonic for the brain
impaired Doc
   A for alcoholism
   E for encephalopathy
   I for insulin
   O for opiates
   U for uremia
   T for trauma and environmental disturbance
   I for infection
   P for psychiatric
   S for syncope
Alcoholics have many reasons to
be impaired
   Head trauma, hypothermia
   Infections: pneumonia, meningitis, sepsis
   Withdrawal: delerium tremens, post-ictal
   Metabolic: alcoholic ketoacidosis, lactic acidosis
   Brain atrophy, Wernicke’s, Korsakoff’s, lead
    encephalopathy
   Toxic alcohols: methanol, isopropyl, ethylene
    glycol
   Liver failure, hypoxia
E for encephalopathy
   Post-ictal
   Hypertensive Encephalopathy
   Intracerebral mass
   CVA - vasocclusive
     • thrombosis
     • embolism
     • venous infarct
   CVA- hemorrhagic
     • Intracerebral hemorrhage
     • Subarachnoid hemorrhage
I for insulin
   Too little
    • Diabetic Ketoacidosis
    • Hyperosmolar Non-ketotic Coma


   Too much
    • Hypoglycemia
O for opiates
   Essentially any chemical including water

   sedatives
   anticholinergics
   hallucinogens
   sympathomimetics
U for uremia
   Hyper and hypo Na, hyper and hypo Ca,
    hyper and hypo Mg, hypophosphatemia
   Hyper and hypo T4, Hyper and hypo
    adrenal, panhypopituitarism
   Liver, renal, and exocrine pancreas failure,
   HYPERCARBIA
   HYPOXIA, HYPOXIA, HYPOXIA
T for trauma and environmental
disturbance
     Epidural, Subdural, Subarachnoid and
      intracerebral hemorrhage
     Concussion and contusion
     Hypo and hyperthermia
I for infection
   Meningitis
   Sepsis
   Brain abscess
   Encephalitis
   The weirdos: cerebral syphillis, malaria,
    tuberculosis, cystocercosis, nagleria,
    cryptococcosis, toxoplasmosis, etc
P for psychiatric
   Hysteria
   Malingering
   Catatonia
S is for syncope
   Arrhythmias
   Infarction
   Hypovolemia
   Hemorrhage
   Vasodepressor syncope
Causes of Stupor or Coma in 500
patients
   Diffuse dysfunction 76%

   Supratentorial lesions 20%

   Subtentorial lesions 12%

   Psychiatric 8%
Things that aren’t coma
   Dementia
   Acute Confusional State (Delerium)
   Persistent Vegetative State
   Akinetic Mutism
   Locked in syndrome
   Psychogenic Unresponsiveness
   Brain death
When altered but not Coma, check
components of consciousness
   Wakefulness
   Attention
   Working Memory
   Perception
   Long-term Memory
   Motivation
   Cognition
   Purposeful motor response
Initial actions
   Check SaO2 and pupils, support respiration
    and oxygenation, Narcan for suspected
    narcotics OD
   Check BP and conjunctiva, treat shock and
    anemia
   Glucometer, admin glucose if indicated
Two minute exam, Is it
structural?
   History
   Pupillary reactions
   Oculocaloric respones
   Respiratory pattern
   Motor responses
   Skeletal tone

   Should have 95% accuracy of structural vs
    diffuse dysfunction
Is it structural: History
   Sudden vs. gradual onset
   PMH: particulary depression, Diabetes,
    Drug user, medications prescribed or
    missing
Is it structural: pupillary
reactions
   Metabolic: small reactive
   Diencephalic: small reactive
   Midbrain: midposition, fixed
   CN III: unilateral dilated
   Pons: pinpoint fixed
   Medulla: dilated, fixed
   Tox: narcotics -pinpoint reactive, hypoxic,
    barbs - dilated and fixed
Oculocalorics
   Brainstem intact: deviates to cold water

   Brainstem damaged: anything else

   Low brainstem: no response

   COWS is backwards, patient must have live
    vestibule, no vestibular toxic drugs
Respiratory Pattern
   Eupnea: diffuse dysfunction
   Cheynes-Stokes: Diencephalon
   Sustained hyperventilation: Midbrain
   Ataxic: Medullary
Motor Responses and tone
   Diffuse: aversive reactions
   Early diencephalon: aversive &
    cogwheeling
   Low diencephalon: flaccid or decorticate,
    tone decreased
   Midbrain: flaccid or decerebrate
   Medulla: lower extremity flexion
Diffuse dysfunction
   Pupils small and reactive
   Oculocalorics: tonic deviation
   Tone: normal
   No posturing, normal tone
   Normal breathing of Cheyne-Stokes
Psychogenic unresponsiveness
   Eyelids flutter and close actively
   Pupils small and reactive
   Tone variable, bizarre posturing may be
    present
   Optokinetic testing positive
   Oculocalorics: fast component present
Supratentorial Mass
   Initially focal signs (the mass)
   Signs move rostral to caudal
   Signs point to one level at any time
   motor signs may be asymmetrical
Supratentorial herniation
   Central

   Uncal

   Combined
Early diencephalic phase
   Eupnea
   Pupils small and reactive
   conjugate deviation
   aversive motions
   cogwheeling (paratonia)
Late diencephalic
   Cheyne-Stokes breathing
   Pupils small and reactive
   Conjugate deviation: easier less cortical
    control
   Flaccid or decorticate
Mid-brain upper pons
   Sustained hyperventilation
   pupils mid position, fixed irregular
   oculocalorics impaired, dysconjugate
   flaccid or decerbrate
Lower pons, upper medulla
   Ataxic breathing
   pupils midposition fixed irregular
   No caloric response
   flaccid or L.E. flexion
Uncal herniation - early 3rd
nerve
   Eupneic
   Dilate pupil, sluggish
   full or dysconjugate oculocalorics
   aversive movements, paratonia,
   Patient may be awake
Uncal herniation Late 3rd nerve
   Sustained hyperventilation
   Dilated pupil, lid droops,
   Eye moves out and down
   Decorticate posturing
Subtentorial lesions
 Pontine hemorrhage or infarction
 Tumors
 Cerebellar hemorrhage: if treated surgically
  before coma ensues, patient may achieve normal
  neurolgic recovery

 Signs point to one level and stay there
 Cranial nerve findings common
 Vertigo and nystagmus often prominent
Initial diagnostic eval: all
patients
   Lytes, BUN, Glucose
   Measured osmolality
   ABGs and cooximetry
   Urinalysis
Selected studies for some patients
   Imaging
   LP
   Endocrine, Liver function
   Cultures (blood, CSF)
   Toxicology
   ECG
Management
   Oxygen, ventilation, airway protection
   Circulation
   Glucose and thiamine, narcan
   lower intercranial pressure
   Control seizures
   Treat infection
   Correct acid-base disturbances
Management
   Correct electrolytes
   Correct body temperature
   Specific antidotes
   Control agitation
Oh yes, and our herniating lady
   Patient was intubated and hyperventilated
   Mannitol was given
   Neurosurgeon was paged stat
   He placed an intraventricular drain, clear
    CSF squirted across the room. . .
And she woke up
   Patient was taken to angio suite where a 4
    vessel revealed bilaterally greatly enlarged
    ventricles
   Dye down the drain revealed a non-
    communicating hydrocephalus with block
    below the 4th ventricle
   Subsequent records from the warehouse
    revealed that she had been admitted for 6
    months at age 18 months
DX: Hydrocephalus residual
from TB meningitis 18 yrs before
   Patient was given a Ventriculo-peritoneal
    shunt, was doing well 6 months later
Lessons
   Her neck wasn’t stiff and she wasn’t
    resisting ROM, she had paratonia
   She had no focal findings because the
    lesions were bilateral and symmetrical
   Neurosurgeons are handy

   It’s better to be lucky than good
Case 2
 37 yo M found down at place of business at 5 am
 On arrival to ED: Tachypneic, tachycardic,
  hypertensive, diaphoretic and retching.
  Unresponsive to voice or pain. Pupils 2 mm
  bilaterally and unresponsive to light. Does not
  move extremities.
 Pt paralyzed, intubated and sedated
 What are the possible diagnoses? How should we
  work it up?
Case 2 possible Diagnoses
   Mixed overdose with narcotic effect pupils
    possible but unlikely: narcan had no effect
   Intracerebral hemorrhage with
    intraventricular extension leading to sudden
    central herniation
   Primary pontine lesion, if onset were
    sudden, more likely a bleed than a stroke

								
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