ALTERED LEVEL OF CONSCIOUSNESS

Identify the term:

• Aware that you are aware

• Recognize out awareness of self environment

Sensorium

Components of Sensorium

• Consciousness

• Attention span

• Orientation to time, place, and person

• Fund of information → familiar with current events; asks questions about the environment

• If uninterested = psychological issues

• Insight, judgment, and planning

• Calculation

Functions of Sensorium:

• Registers current ________(i.e. anxiety to do better, hunger) and _________ contingencies (i.e. there is a fire so call a firetruck, environment)

• Relates current internal and external stimuli to our _________ and future hopes and desires

• Invests the streams of afferent stimuli with _________ , determines their significance, and assigns priority that results in neglect or attention

• Proposes various __________ and their __________

• Directs motor system in behaviors for personal _______and __________

• Allows us to experience life as a __________ person with a past, present, and future to respond appropriately

Functions of Sensorium:

• Registers current internal (i.e. anxiety to do better, hunger) and external contingencies (i.e. there is a fire so call a firetruck, environment)

• Relates current internal and external stimuli to our memories and future hopes and desires

• Invests the streams of afferent stimuli with emotion, determines their significance, and assigns priority that results in neglect or attention

• Proposes various actions and their consequences

• Directs motor system in behaviors for personal survival and satisfaction

• Allows us to experience life as a conscious person with a past, present, and future to respond appropriately

State of full awareness of self and environment and normal responsiveness to external stimulation and inner needs

Consciousness

Consciousness is dependent on these two elements

Arousal and Awareness

This element of consciousness depends on the integrity of the cerebral cortex

Awareness (Content)

This element of consciousness depends on the integrity of the ascending reticular activation system (ARAS)

Arousal (Wakefulness)

True or False:

A normally attentive person’s attention can fluctuate during the day but can be brought immediately to a state of full alertness and mental function

True

• Inability to think with customary speed, clarity, and coherence 

• Impaired judgement and decision-making

• Most often due to a process that affects the whole brain (encephalopathies or dementia)

Confusion

Most events that involve the confused patient leave no trace of ________?

Memory

Inability to integrate and attach symbolic meaning to experience

Apperception

In ________ patients, the degree of confusion can vary from hour to hour

Dementia patients

Identify the condition:

Pt is attentive during the morning and it decreases, peak confusion in the early evening hours

Sundowning

Tests for confusion:

• Recall events

• Serial subtraction or spelling backwards or digit span backwards

• Test for impaired registration

• Severe inattentiveness, altered mental constent and sometimes hyperactivity

• Characterized by misperception of sensory stimuli, often with hallucinations

Delirium

People with delirium are disoriented first to ______, next to _______ then to __________ in their environment.

• First to time

• Next to place

• Then to people in their environment

Common type of delirium that is usual in patients with alcohol withdrawal

Delirium tremens

Symptoms of delirium tremens (read and pray)

• Tremors in hands

• Chest pain

• Rapid heartbeat

• High blood pressure

• Fainting or passing out

• Confusion, anxiety

• Hallucination

• Heacy sweating, pale skin

• Fever

• Nausea and vomiting

• Sleepiness or fatigue

• Sensitivity to light or sound

• Severe dehydration

• Hyperactivity or excitability

• Seizures

Inability to sustain a wakeful state without application of external verbal stimuli 

• Patient shifts positions naturally and without prompting 

• Lids droop, may snore, limbs relaxed

• Decreased mental, speech, and physical activity

Drowsiness

Some degree of __________ and __________ coupled with drowsiness improves with arousal

Inattentiveness and mild confusion

• Mental blunting 

• Mild to moderate reduction in alertness, accompanied by a lesser interest in the environment 

• Slower response to stimulation 

• Non-painful physical stimulation

Obtundation

• Lt. “to be stunned” 

• Reduction or elimination of natural shifting of positions

• Patient can only be awakened or aroused by vigorous and repeated painful stimuli and usually repeated stimulation is required to sustain arousal 

Stupor

In patients with stupor how are the eyes displaced

Slightly out and up (Same as people asleep)

Identify which condition can be awakened by the following stimulation:

• Noxious stimulation (Trap squeeze, sternal rub, deep nail bed pressure, supraorbital pressure)

• Verbal stimulation or command

• Light physical non-painful stimuli

• Stupor

• Drowsiness

• Obtundation

• Gk. “deep sleep or trance” 

• Incapable of arousal by external stimuli or inner need

Coma

In ___________ of coma, corneal, pupillary, and pharyngeal reflexes can be elicited

Lighter stage

In_________ of coma, no meaningful or purposeful reaction of any kind is obtainable and corneal, pupillary, and pharyngeal responses are diminished

deepest stage

• Patients who, after recovery from coma, return to a state of wakefulness without cognition 

• Eyes open permanent unconsciousness with loss of cognitive function and awareness of the environment but preservation of sleep-wake cycles and vegetative function 

Persistent Vegetative state

Persistent Vegetative State

• If vegetative syndrome of unconscious awakening persists for__________ after non-traumatic brain injury or ________ after traumatic injury

Cortex is diffusely injured or disconnected from ________

• 3 months

• 12 months

• thalamus

Causes of persistent vegetative state

• Anoxia → ischemia (worst prognosis) 

• Metabolic or encephalitic coma 

• Head trauma

MRI of Persistent vegetative state:

• Global brain ________

• _______ and ________ are disproportionately affected

• atrophy of ________

• Secondary __________ enlargement

• Thinning of the _________

MRI of Persistent vegetative state:

• Global brain atrophy

• Thalamus and basal ganglia are disproportionately affected

• atrophy of white matter

• Secondary ventricular enlargement

• Thinning of the corpus callosum

EEG of Persistent vegetative state

• ____________ in background EEG activity during and immediately after stimulation of patient

Neuroimaging of Persistent vegetative state

• Progressive and profound ________ atrophy

EEG of Persistent vegetative state

• lack of normal change in background EEG activity during and immediately after stimulation of patient

Neuroimaging of Persistent vegetative state

• Progressive and profound cerebral atrophy

State of coma where brain was irreversibly damaged and has ceased to function, but pulmonary and cardiac function could still be maintained by artificial means

Brain Death

Brain Death

• State of complete unresponsiveness in all modes of stimulation, arrest of respiration, and absence of all EEG activities for _________

• A person is dead if the brain is dead and that death of brain may precede the cessation of ____________

Brain Death

• State of complete unresponsiveness in all modes of stimulation, arrest of respiration, and absence of all EEG activities for 24 hours

• A person is dead if the brain is dead and that death of brain may precede the cessation of cardiac function

• Deep coma 

• Total lack of spontaneous movement and of motor and vocal responses to all visual, auditory, and cutaneous stimuli

Absence of Cerebral Function

Absence Of Brainstem Function:

• Loss of ________ response

• Loss of ________ , ________ , ________ reflex

• Absence of ________ movement to noxious stimuli

• Absence of ________ mediated movement to noxious stimuli of extremities

Absence Of Brainstem Function:

• Loss of pupillary response

• Loss of corneal, oculocephalic, gag and cough reflex

• Absence of facial movement to noxious stimuli

• Absence of cerebrally mediated movement to noxious stimuli of extremities

Tests for Brain Death

• Apnea Test

• Absence of tachycardia

• EEG

• Digital subtraction angiography

• Toxicology screening

• Isoelectric EEG

Apnea Test

• Destruction of _______

• Unresponsiveness of ________ centers to high carbon dioxide tension

• PaCO2 _________ (normal _______)

Apnea Test

• Destruction of medulla

• Unresponsiveness of medullary centers to high carbon dioxide tension

• PaCO2 60mmHg (normal 35-45mmHg)

Absence of Tachycardia

•  in response to ___________

  • Reflects loss of cardiac innervation by damaged _________ neurons 

• Use of __________

Absence of Tachycardia

•  in response to atropine 

  • Reflects loss of cardiac innervation by damaged medullary vagal neurons 

• Use of anticholinergic

EEG

• Confirms _________

• _________ silence, flat, or _________ EEG

EEG

• Confirms brain death

• Electrocerebral silence, flat, or isoelectric EEG

Digital Subtraction Angiography (DSA)

• lack of contrast ________during 4VA

Digital Subtraction Angiography (DSA)

• lack of contrast opacification during 4VA

This is used to To rule out reversible cause or to determine that cause is irreversible and not for confirmation of brain death (poisons)

Toxicology Screening

Isoelectric EEG

• with preserved ________ reflexes 

  • ________ or _________ with sedative-hypnotic drugs and immediately post-cardiac arrest

Isoelectric EEG

• with preserved brainstem reflexes 

  • Hypothermia or intoxication with sedative-hypnotic drugs and immediately post-cardiac arrest

Scale used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients

Glasgow Coma Scale (GCS)

Who created the GCS

 Graham Teasdale and Bryan Jennett 

3 aspects of the GCS

• Eye opening

• Verbal response 

• Motor response

Eye-Opening (E) : Identify grade

• opens eyes to voice

• no eye-opening

• open eyes spontaneously

• opens eyes to pain

Eye-Opening (E)

• Grade 3

• Grade 1

• Grade 4

• Grade 2

Best Verbal Response (V): Identify grade

• incomprehensible (moans/groans/ sounds)

• no sound

• confused

• appropriate and oriented

•  inappropriate words

  
  

Best Verbal Response (V): Identify grade

• Grade 2

• Grade 1

• Grade 4

• Grade 5

• Grade 3

Best Motor Response (M): Identify grade

• abnormal flexor response Decorticate

• obeys commands

• withdraws to pain (normal flexion)

• no movement

• localizes to pain

• abnormal extensor response Decerebrate

Best Motor Response (M): Identify grade

• Grade 3

• Grade 6

• Grade 4

• Grade 1

• Grade 5

• Grade 2

GCS of Head Injuries and Traumatic Brain Injuries (TBI)

• 13-15

• 9-12

• 3-8

• WITH GCS-P: 1-8

GCS of Head Injuries and Traumatic Brain Injuries (TBI)

• Mild TBI

• Moderate TBI

• Severe TBI

• Severe TBI

Initial Diagnostic Work-up and Emergent Management (SKIM)

1. Establish and maintain airway, breathing, and circulation (ABCs) 

2. Monitor vital signs 

3. Initial fluid management 

4. Assess neurologic function 

5. Laboratory screening 

6. Initiate specific treatment 

7. Obtain detailed history and perform systemic examination 

8. Perform additional diagnostic tests

What Makes a Case Neurologic? (3 things)

• Focal neurologic deficit 

• Increased ICP

• Meningeal irritation

Neurologic problems: (SKIM AGEN)

• Congenital/developmental 

• Trauma → epidural/subdural/subarachnoid/intracerebral hemorrhage 

• Infectious → meningitis, encephalitis, brain abscess 

• Degenerative 

• Metabolic/endocrine 

• Nutritional deficiency 

• Vascular → cerebral infarction/hemorrhage/SAH 

• Demyelinating 

• Immunologic 

• Neoplastic/mass lesion → neoplasm, abscess, hematoma, granuloma, cyst 

Disease Categories: VINDICATE (wat dat mean tho?)

• Vascular

• Infectious 

• Neoplastic 

• Degenerative 

• Inflammatory/iatrogenic/idiopathic 

• Congenital 

• Autoimmune/allergic 

• Traumatic 

• Endocrine/metabolic

TYPES OF LESION: Identify

• Mass lesion, infarction, hematomas

• Multiple tumors, mass lesions

• Metabolic endocrine, toxic encephalopathy 

TYPES OF LESION: Identify

• Focal

• Multifocal

• Diffuse

Types of causes of Alteration in Consciousness

• Structural

• Functional

Causes of Alteration in Consciousness

• Discrete lesion 

• Widespread destructive changes of the hemispheres 

• Increased ICP

Structural

Causes of Alteration in Consciousness

• Metabolic, toxic, nutritional d/t neuronal failure in the cerebrum and RAS

  
  

Functional

Discrete Lesions:

• Secondary Compression of ARAs

• Direct Damage to ARAs

• Widespread Bilateral Damage to Cortex and Cerebral White Matter

• Large mass in one cerebral hemisphere 

• Tumor, abscess, massive infarct, intracerebral, subdural, or epidural hemorrhages, or large cerebellar lesion

Secondary Compression of ARAs

• Destructive lesion immediately within thalamus or midbrain

Direct Damage to ARAs

• Trauma, bilateral strokes or hemorrhages, encephalitis, meningitis, hypoxia (cardiac arrest), or global ischemia 

• Interruption of thalamocortical impulses or generalized destruction of cortical neurons

Widespread Bilateral Damage to Cortex and Cerebral White Matter

Intracranial complications of trauma

• Epidural hemorrhage

• Subdural hemorrhage 

• Subarachnoid hemorrhage 

• Intracerebral hemorrhage 

All intracranial complications of trauma are acute except?

Subdural hematoma

which can be acute, subacute, or chronic 

Cerebrovascular Accident (3 characteristics)

• Infarction 

• Hemorrhage 

• Acute

Infection

• Meningitis

• Encephalitis

• Meningoencephalitis

• Abscess

Infectious structural lesion that is diffused

Encephalitis

Infectious structural lesion that affects both brain and meninges and may be acute, subacute, or chronic

Meningoencephalitis

Infectious structural lesion that is focal or multifocal and is only chronic

Abscess

Meningeal irritation that’s acute with fever

Acute meningitis

Meningeal irritation that’s acute but with no fever

SAH

Meningeal irritation that’s chronic with fever

Chronic meningitis

Identify if the FND is in the cerebrum, brainstem or cerebellum:

• Ipsilateral cranial nerve deficit

• Behavioural, personality, and mental changes

• Contralateral hemiparesis and Babinski 

• Truncal Ataxia 

• Limb Ataxia 

• Contralateral hemiplegia with Babinski 

• Contralateral hemisensory deficit 

• Visual field defect

• Contralateral hemisensory deficit

• Seizure

• Language problem

Identify if the FND is in the cerebrum, brainstem or cerebellum:

• Ipsilateral cranial nerve deficit = BRAINSTEM

• Behavioural, personality, and mental changes= CEREBRUM

• Contralateral hemiparesis and Babinski = CEREBRUM

• Truncal Ataxia = CEREBELLUM

• Limb Ataxia = CEREBELLUM

• Contralateral hemiplegia with Babinski = BRAINSTEM

• Visual field defect= CEREBRUM

• Contralateral hemisensory deficit= CEREBRUM & BRAINSTEM

• Seizure= CEREBRUM

• Language problem= CEREBRUM

FNDs that are acute and vascular in origin

• Ischemic

• Hemorrhagic

FNDs that are chronic in origin

• Degenerative disease

• Mass lesion

Types of mass lesion

• Neoplastic

• Abscess

• Granuloma

• Hematoma

• Cyst

Acute Increased ICP that arises from trauma

• Epidural hematoma

• Subdural hematoma

• Subarachnoid hemorrhage

• Parenchymal hemorrhage

Increased ICP that is acute and atraumatic in origin with no fever

• Cerebral infarction

• Cerebral hemorrhage

• Subarachnoid hemorrhage

Increased ICP that is acute and atraumatic in origin with fever

Acute meningitis

Increased ICP that is chronic

• Mass lesion (tumor)

• Chronic meningitis

• Hydrocephalus

Causes of Alteration in Consciousness (Metabolic)

• Glucose (increased or decreased) 

• Oxygen (diminished) 

• Fluid (increased or decreased)

• Electrolytes (increased or decreased) 

• Acidosis or alkalosis 

• Excess endogenous wastes (creatinine, ammonia, CO2)

Toxic Causes of Alteration in Consciousness

• Exogenous toxins

• Poisons

• Chemicals

• Drugs

Nutritional Deficiency which can lead to alterations in conciousness

B1, B6, B12

initial presentations of encephalopathies

Behavioral and personality changes

• Acute confusional episode 

• Delirium

Encephalopathy

• Alteration of _________

• _________ seizures 

• _________ are usually absent, but _________ if present

Encephalopathy

• Alteration of consciousness 

• Generalized seizures 

• FND are usually absent, but bilateral if present

22 y/o ♂ c 4 days hx of fever, HA, body malaise, loss of appetite

BP: 100/70; febrile (39.7 deg C)

Arousable to name calling but remains sleepy, oriented to place, time, & person; able to follow simple commands

GCS14 E3 V5 M6

On examination, (+) resistance on passive neck flex

• What is the GCS score of the patient?

• What is the level of consciousness of the patient?

• What is the GCS-P score of the patient?

• Resistance on passive neck flexion is called _____.

• What makes the problem neurologic?

• What is the cause of alteration in sensorium?

22 y/o ♂ c 4 days hx of fever, HA, body malaise, loss of appetite

BP: 100/70; febrile (39.7 deg C)

Arousable to name calling but remains sleepy, oriented to place, time, & person; able to follow simple commands

GCS14 E3 V5 M6

On examination, (+) resistance on passive neck flex

• 14

• Drowsy

• N/A

• Nuchal Rigidity

• Meningeal Irritation

• Meningitis

70 y/o ♀ c 6 mo hx of progressively inc severity & frequency of frontotemporal HA ; c/o weakness of (L) hand

BP: 130/70; PR: 70; afebrile

NE:

Spontaneous eye-opening, appropriate responses to questions, follows commands

(+) papilledema, OU

MMT: ⅘ on (L) UE & LE

(+) (L) sensory deficit

(+) (L) Babinski

• What is the level of consciousness of the patient?

• What is the GCS score of the patient?

• What makes the problem neurologic?

70 y/o ♀ c 6 mo hx of progressively inc severity & frequency of frontotemporal HA ; c/o weakness of (L) hand

BP: 130/70; PR: 70; afebrile

NE:

Spontaneous eye-opening, appropriate responses to questions, follows commands

(+) papilledema, OU

MMT: ⅘ on (L) UE & LE

(+) (L) sensory deficit

(+) (L) Babinski

• Normal

• 15

• Inc ICP and Weakness