Consciousness disturbance

You have to ask yourself…….. 1這是一個意識不清的病人嗎?他的意識狀態為何? 2這是個stable 的病人嗎? 3造成病人意識不清的原因為何? 4 我要詢問哪些重要的病史,要做哪些理學檢查?有甚麼可用的診斷工具? 5要如何治療這個病人?

意識狀態與昏迷 意識狀態：對本身和環境具有察覺與認知的能力 客觀評估： 外表：清醒或睡眠 狀態 行動：自主及隨意性 ，對刺激有意義 的反應 昏迷：對本身和環境不具有察覺與認知的能力 客觀評估： 外表：睡眠狀 行動：對刺激不能產 生有意義的反應

意識之成分 喚醒度(Arousal): 1.臨床現象：外表上呈醒的狀態 (能主動睜眼或對外界刺激有睜眼反應） 2.是腦幹之網狀系統活動的表現 3.主為腦幹之功能 覺察能力(Awareness)： 1.綜合認知和情感之腦功能 2.臨床現象：有意義的動作和語言 3.主為大腦半球的功能

Mental status-terms Awake--eye open and talking (E4) Somnolent-- eye closed, but open to voice (E3) Lethargic– eye closed, but open to pain (E2) Obtunded– eye closed, do not open to voice or pain (E1) Stupor--(hypersomnia) is an excessively long or deep sleeplike state from which a person can be awakened only briefly by vigorous stimulation, such as repeated shaking, loud calling, pinching, or sticking with a pin. Coma--is a state of complete unresponsiveness, from which a person cannot be aroused at all.

Orientation Name Place Year and date If not, -- confused Glasgow Coma Scale (GCS) E - Eye Response睜眼反應 V- Best Verbal Response M- Best Motor Response

Cause of consc. disturbance Intracrainal : hemorrhage , ischemic ,infection , tumor ,seizure Extracrainal : intoxications ,Metabolic abnormalities ,endocrine ,hypoxia , Imbalance of electrolytes , hypotension, Psychogenic

病史 What was the time course of the loss of consciousness? Did focal signs or symptoms precede the loss of consciousness? What recent illness has the patient had? Has there been altered behavior or function recently? Medication history

Five key physical findings Level of consciousness Pupils Oculocephalic reflex Respiratory pattern :Cheyne-Stokes respiration, Hyperventilation ,apneustic breathing ,Biot's breathing: Motor tone and responses

Glasgow Coma Scale (GCS) E - Eye Response睜眼反應 4分：自然睜眼(spontaneous) 3分：呼喚會睜眼(to speech) 2分：有刺激或痛楚會睜眼(to pain) 1分：對於刺激無反應(none)

V- Best Verbal Response 5分：說話有條理(oriented)。 4分：可應答，但有答非所問的情形(confused)。 3分：可說出單字(inappropriate words)。 2分：可發出聲音(unintelligible sounds)。 1分：無任何反應(none)。

M- Best Motor Response 6分：可依指令動作(obey commands)。 5分：施以刺激時，可定位出疼痛位置(localize)。 4分：對疼痛刺激有反應，肢體會回縮(withdrawal)。 3分：對疼痛刺激有反應，肢體會彎曲(decorticate flexion)。 2分：對疼痛刺激有反應，肢體會伸直(decerebrate extension)。 1分：無任何反應(no response)。

Abnormal eye movements spontaneous horizontal conjugate eye movements,  normal brainstem function , metabolic coma persistent conjugate deviation of the eyes towards one side  stroke or seizure hemispheric stroke conjugatedly deviated away from the side of hemiplegia, Brainstem conjugatedly deviated toward the side of hemiplegia

Decorticate vs Decerebrate posturing

Abnormal breathing patterns Absent Present Clinical feature Metabolic coma Brainstem coma Abnormal breathing patterns Absent Present Abnormal posturing Spontaneous conjugate gaze movements Conjugate gaze movements inducible by caloric testing or Doll's eye Persistent horizontal conjugate deviation of eyes Absent (hemisphere strokes - away from the side of any hemiplegia) May be present towards the side of any hemiplegia  Briskly reactive pupils in deep coma Present (Absent in certain drug overdoses) Abnormal automatisms (coughing, swallowing, or hiccuping) May be present

Emergent evaluation (-) Vital signs and primary management (ABC) body position at rest pupils  size ,light reflex , eye position and movement petechial rash or IV drug needletracks evidence of tongue biting odor of breath

Emergent evaluation (二) patient response to verbal stimuli ,to painful stimuli gag reflex, motor tone presence of nuchal rigidity, trismus, abnormal plantar reflexes evidence of urinary incontinence

Emergent evaluation (三) CBC with platelets ,PT/PTT serum electrolytes, calcium and magnesium serum liver function tests, ammonia serum alcohol , carboxyhemoglobin ABG urine toxic screen +/- thyroid or adrenal function tests, serum Head CT scan ,Brain MRI Lumbar puncture:

MANAGEMENT Glucose 50 percent IV 50mL (after blood drawn, before results back) Thiamine 100mg IV Ceftriaxone , Vancomycin , Acyclovir: for possible infection Naloxone , Flumazenil ,Gastric lavage/activated Mannitol Lorazepam , Phenytoin etc