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Impaired Consciousness

Impaired Consciousness. Dr Nin Bajaj Consultant Neurologist QMC & DRI. Assessment. Glasgow Coma Scale Eye opening-(E) Spontaneous-4 To speech-3 To pain-2 None-1. GCS. Best Motor Response- (M) Obeys-6 Localises-5 Withdraws-4 Abnoraml flexion-3 Abnormal extension-2 None-1. GCS.

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Impaired Consciousness

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  1. Impaired Consciousness Dr Nin Bajaj Consultant Neurologist QMC & DRI

  2. Assessment • Glasgow Coma Scale • Eye opening-(E) • Spontaneous-4 • To speech-3 • To pain-2 • None-1

  3. GCS • Best Motor Response- (M) • Obeys-6 • Localises-5 • Withdraws-4 • Abnoraml flexion-3 • Abnormal extension-2 • None-1

  4. GCS • Verbal Response(V) • Orientated-5 • Confused conversation-4 • Inappropriate words-4 • Incomprehensible sounds-3 • None-1

  5. History • Acute • Subacute • Chronic

  6. Acute- quick recovery • Syncope- vasovagal, cough, micturition, carotid hypersensitivity, circulating volume • Apnoea- hyperventilation, sleep • Cardiac- arrythmia

  7. Acute impairment- no previous hx • Usually implies a vascular event • Hemispheric bleed or thrombo-embolic stroke • Subarachnoid haemorrhage • Brain-stem event • Bleed into a tumour?

  8. Acute impairment- previous hx • Might be post-ictal

  9. Subacute impairment • Hours-Days • Implies systemic or CSF process • Possibly raised ICP

  10. Subacute-systemic • Electrolyte imbalance- uraemia, hyperammonaemia, hypo/hypernatraemic • Endocrine- hypothyroid, Addisonian • Infection + with reduced cognitive reserve

  11. Subacute- CSF process • Meningitis/Encephalitis • Neoplastic • Inflammatory- ADEM, MS, Vasculitic, Sarcoid

  12. Subacute- raised ICP • Usually a rapidly growing tumour • Consider cerebral venous thrombosis • Might end up coning

  13. Chronic • Neurodegenerative- Lewy Body, Prion, AD • Chronic Vascular • Drug induced- e.g. Anti-cholinergics, dopaminergic agents • Sleep attacks e.g. narcolepsy, synuclein deposition

  14. Is it a stroke? • Hemispheric- should be localising neurology • Bleeds tend to be worse than embolic • Big MCA infarcts worse • Can be raised ICP complicating picture

  15. Is it a stroke? • Needs urgent CT brain • Outside UK, might thrombolyse • For big MCA, consider skull vault removal or dexamathasone/mannitol/over-breathing

  16. Thrombolysis for Stroke- Inclusion Criteria • Ischaemic stroke • Measurable deficit on NIH stroke scale • No evidence of intracranial bleed on CT brain • 180 minutes or less from time of symptom onset to intiation of IV rt-PA • IV rt-PA 0.9 mg/kg, 10% as bolus, 90% as infusion over 60 min

  17. Have they had a SAH? • Sudden onset • Worse headache ever, like “someone hitting me over the head” • Often nausea, vomiting, diplopia, neck stiffness, photophobia • Time to peak pain seconds-minutes • Pain can last hours, less often days

  18. Have they had a SAH? • Not to be confused with thunderclap headache or sex-associated headache • Sentinel bleed can occur • Need Urgent CT brain (remains abnormal for up to 6-10 days) • If negative, need LP after 12 hours and before 2 weeks (range 12-33 days) for xanthochromia

  19. Have they had a SAH? • If confirms dx, need nimodipine 60 mg/4hr PO, and fluids (>3l) • Consider urgent or elective clipping or neuroradiological coiling following formal angiography • Endovascular approaches generally best unless wide-necked aneursym

  20. Have they had a fit? • Classification • Generalised or partial • Grand mal or Petit mal (3Hz spike & wave) • Simple partial or Complex

  21. Have they had a fit? • Markers • Short, minutes only • Tongue biting, urinary incontinence, sterotyped movements • GTCS or CPS localising features • Drowsy and confused afterwards

  22. Causes • Usually primary- ?related to cellular migration defects or channelopathy • Secondary causes include SOL, drugs, stroke, alcohol

  23. Management • ABC • First fit- conservative, CT brain, refer to a neurologist • Known epileptic- review drug management

  24. Established Epilepsy- Drugs • Epilim for GTCS but not females • Lamotrigine GTCS in females • Tegretol for CPS or Lamotrigine if female • Phenytoin- status only

  25. Status Epilepticus • Definition: • “generalised convulsive status epilepticus in adults and older children (>5) refers to more than 5 minutes (USED to be 30 min) of (a) continuous seizures or (b) two or more discrete seizures between which there is incomplete recovery of consciousness”

  26. Status Epilepticus • Continuing seizure activity for >30 min • Diazepam 10-20 mg • Lorazepam 4 mg IV • ABC • Phenytoin, 15-18 mg/kg as IV over 20-30 min, cardiac monitor • Transfer to ITU, phenobarbitone and propofol, CFM

  27. Syncope and Seizure • Postural only? • Feel hot, clammy- “cold sweat” • Vision dark around edges • LOC seconds only • No tb, ui, drowsiness, confusion • ?arrythmia, pale as a sheet • micturition, cough, emotional trigger • Hyperventilation, migraine • Carotid sinus- e.g. stiff collar

  28. Investigating Syncope • ECG- look for WPW, long QT syndromes • If abnormal, 24hr ECG or loop monitor • Postural BP • Tilt table with CSM

  29. Management • Emotional or specific trigger- avoid stimulus • Neurogenic with positive tilt table- salt and fluids, orthostatic training, fludrocortisone, midodrine • Cardiac- pacemaker

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