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Altered Mental Status and Coma

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.

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Altered Mental Status and Coma

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  1. Altered Mental Status and Coma Brian Nelson

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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?

  7. 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

  8. 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

  9. 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

  10. 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

  11. E for encephalopathy • Post-ictal • Hypertensive Encephalopathy • Intracerebral mass • CVA - vasocclusive • thrombosis • embolism • venous infarct • CVA- hemorrhagic • Intracerebral hemorrhage • Subarachnoid hemorrhage

  12. I for insulin • Too little • Diabetic Ketoacidosis • Hyperosmolar Non-ketotic Coma • Too much • Hypoglycemia

  13. O for opiates • Essentially any chemical including water • sedatives • anticholinergics • hallucinogens • sympathomimetics

  14. 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

  15. T for trauma and environmental disturbance • Epidural, Subdural, Subarachnoid and intracerebral hemorrhage • Concussion and contusion • Hypo and hyperthermia

  16. I for infection • Meningitis • Sepsis • Brain abscess • Encephalitis • The weirdos: cerebral syphillis, malaria, tuberculosis, cystocercosis, nagleria, cryptococcosis, toxoplasmosis, etc

  17. P for psychiatric • Hysteria • Malingering • Catatonia

  18. S is for syncope • Arrhythmias • Infarction • Hypovolemia • Hemorrhage • Vasodepressor syncope

  19. Causes of Stupor or Coma in 500 patients • Diffuse dysfunction 76% • Supratentorial lesions 20% • Subtentorial lesions 12% • Psychiatric 8%

  20. Things that aren’t coma • Dementia • Acute Confusional State (Delerium) • Persistent Vegetative State • Akinetic Mutism • Locked in syndrome • Psychogenic Unresponsiveness • Brain death

  21. When altered but not Coma, check components of consciousness • Wakefulness • Attention • Working Memory • Perception • Long-term Memory • Motivation • Cognition • Purposeful motor response

  22. 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

  23. 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

  24. Is it structural: History • Sudden vs. gradual onset • PMH: particulary depression, Diabetes, Drug user, medications prescribed or missing

  25. 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

  26. 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

  27. Respiratory Pattern • Eupnea: diffuse dysfunction • Cheynes-Stokes: Diencephalon • Sustained hyperventilation: Midbrain • Ataxic: Medullary

  28. 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

  29. Diffuse dysfunction • Pupils small and reactive • Oculocalorics: tonic deviation • Tone: normal • No posturing, normal tone • Normal breathing of Cheyne-Stokes

  30. 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

  31. 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

  32. Supratentorial herniation • Central • Uncal • Combined

  33. Early diencephalic phase • Eupnea • Pupils small and reactive • conjugate deviation • aversive motions • cogwheeling (paratonia)

  34. Late diencephalic • Cheyne-Stokes breathing • Pupils small and reactive • Conjugate deviation: easier less cortical control • Flaccid or decorticate

  35. Mid-brain upper pons • Sustained hyperventilation • pupils mid position, fixed irregular • oculocalorics impaired, dysconjugate • flaccid or decerbrate

  36. Lower pons, upper medulla • Ataxic breathing • pupils midposition fixed irregular • No caloric response • flaccid or L.E. flexion

  37. Uncal herniation - early 3rd nerve • Eupneic • Dilate pupil, sluggish • full or dysconjugate oculocalorics • aversive movements, paratonia, • Patient may be awake

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