Term
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Definition
• “A prolonged state of unconsciousness”
• “unarousable and unable to respond to external stimuli or internal needs” |
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Term
| • Levels of consciousness |
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Definition
• Comatose
• Obtunded
• Stuporous/lethargic |
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Term
| Causes of Altered Mental Status |
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Definition
- Metabolic
• Diffuse cerebral dysfunction, suppression of neural activity
• Diffuse non-localizing findings
• Examples include hypo/hyperglycemia, uremia, hypercarbia, medications, electrolyte disturbances, vitamin deficiencies, infection, drugs, seizure
- Structural
• Bilateral cortical dysfunction or dysfunction of the RAS (reticular activating system)
• Localized neurological findings
• Examples include stroke, trauma, hemorrhage, tumor, and anoxic injury |
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Term
| hx for altered mental status |
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Definition
• Acute vs. Chronic
• Progression of symptoms
• Precipitating factors
- Past medical history: comorbidities, baseline functional
status,
- Social History: Alcohol, substance use/abuse, recent travel
- Medications- prescription or drugs of abuse |
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Term
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Definition
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Term
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Definition
Observe for eye opening when:
• Initially accessing patient
• Speaking name
• Tactile stimulation
- Light touch
- Vigorous shake- avoid if concern about c-spine injury or unknown mechanism of injury
- Central noxious stimulation- sternal rub, skin fold pinch |
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Term
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Definition
• Ask question- “What is your name?” “Where are you?”
• Observe verbal output
- Spontaneous and oriented
- Inappropriate speech - disoriented
- With vigorous stimulation or noxious stimuli |
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Term
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Definition
• Give a command – “Stick out your tongue” • Central noxious stimulation –sternal rub
- Localize - Reach for stimulation
• Peripheral noxious stimulation – nail bed pressure
- Withdrawal from stimulation |
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Term
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Definition
- Posturing responses
• Flexion (decorticate posture)
• Extension (decerebrate posture)
- Motor asymmetry
• Asymmetric motor response =
structural
• Symmetric motor response = metabolic /diffuse |
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Term
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Definition
- ABC’s – “GCS <8, Intubate”
• Airway protection
• Cough mechanism/gag reflex |
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Term
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Definition
Cranial Nerves
• Pupillary function
- Do the pupils react?
- Do the pupils look the same?
• CN 3 compression - Ipsilateral dilation without reaction, uncal herniation suggesting mass lesion
• Pinpoint without reaction – pontine injury
• Pinpoint with reaction – narcotics, meds
Conjugate gaze
- Do the eyes move?
- Do they move together?
• Dysconjugate gaze = brainstem
• CN 6 palsy- sign of increased
intracranial pressure
• Gaze deviation- unilateral cortical suppression, stroke or seizure
• Oculocephalic reflex (Doll’s eyes)
- Eyes roll side to side (OCR’s
present) = metabolic
- Eyes stay fixed (OCR’s absent) = structural
• Pathologic Reflexes
- Suppression of higher cortical activity
• Plantar (Babinski) Response
- Normal – downward or neutral great
toe
- Abnormal – upward great toe and fanning of toes |
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Term
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Definition
• Nuchal rigidity
• Kernig Sign
- Examiner straightens knees with flexed hips
- Patient experiences low back pain
• Brudzinski Sign
- Examiner flexes neck and patient flexes hips in response |
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Term
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Definition
Blood Work
• Initial
- BMP, CBC w/diff, LFT’s, tox screen, EtOH, glucose, ABG, UA, blood cultures, troponin, EKG, CXR
• Secondary
- TSH, ammonia, B12, Thiamine, cortisol
Imaging
• First Step– Non-contrast head CT
- Any concern for structural lesion or acute neurological injury
- History of fall, found down with unknown mechanism, concern for
occult trauma
- Consider cervical spine
• Second Step– MRI
- Diffuse axonal injury, posterior reversible encephalopathy syndrome (PRES), viral encephalitis
• Lumbar puncture
- After head imaging!
- Fluid analysis, cultures
- Pressure measurement – side-lying most accurate
• Consider EEG monitoring
- Subclinical seizures
- Cortical suppression or injury |
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Term
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Definition
- Supportive Measures
• Airway and ventilation management
- Treat underlying cause
• Treatment of infection
• Correction of metabolic derangements • Care of neurological injury |
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Term
| Alcohol Effects on Consciousness |
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Definition
- Delirium tremens
• Alcohol withdrawal
• Anxiety, irritability, tremor, tachycardia, tachypnea, diaphoresis
• Begins 24-72 hours after last drink, persists for 3-4 days
• Treatment – benzodiazepines
• Monitor for dehydration,
electrolyte disturbance
• Complications – seizures, cardiac abnormalities
- Wernicke Encephalopathy
• Malnutrition associated with
chronic alcoholism
• Confusion, ataxia, nystagmus, opthalmoplegia (CN6)
• Thiamine (B1) deficiency – Give IV thiamine
• If untreated can progress to Korsakoff syndrome • Chronic amnesia, confabulation, impaired learning |
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