CM II Week 6 (Altered LOC/Syncope)

consciousness includes

–Arousal (wakefulness; brainstem reticular activating system)

–Awareness (content of consciousness; cerebral cortex)

confusion

disorientation, impaired attention, fluctuating awareness

lethargy

Drowsiness

Decreased alertness; arousable to voice

syncope

Transient loss of consciousness due to reduced blood flow to both cerebral hemispheres or the brainstem

stupor

Arousable only to vigorous or painful stimuli

coma

a sleep-like state with no purposeful response to internal or external stimuli, from which the patient cannot be aroused.

States of Consciousness

• normal consciousness

• confusion "clouding of the sensorium"

• drowsiness and stupor

• coma

Etiological Categories Of Altered LOC

•Structural

•Metabolic

•Toxicologic (drugs)

•Infectious (meningitis)

•Hypoxic/Ischemic

•Endocrine (hyper/hypoglycemic)

major causes of altered mental status (AEIOU TIPS)

•A --> Alcohol, Acidosis

•E --> Epilepsy, Electrolytes (Na**, K, Ca, Mg)

•I --> Insulin (hyperglycemia / hypoglycemic**)

•O --> Overdose, Opiates

•U --> Uremia

•T --> Trauma, Temperature

•I --> Infection

•P --> Psychiatric, Poisoning

•S --> Stroke, Seizures

Initial approach to Altered LOC... Primary Survey

•#1 ABCs!!

•Check glucose immediately

•Pulse ox

•IV access

•Cardiac monitoring

Altered LOC... Focused History

•Onset and progression

•Witness account

•Medications/Toxins (any SI?)

•Seizure Activity

•Trauma or fall

•Past neurologic history

Altered LOC... PE

•Vitals (fever, hypotension, low O2 sat, increased RR)

•Neuro Exam (esp. pupils, gaze deviation, motor asymmetry)

•Signs of trauma

•Signs of infection

Altered LOC... Diagnostic Studies

•Fingerstick glucose

•CBC with diff, CMP, ABG, Tox screen

•Non-contrast CT of head (check for hemorrhage)

•ECG

•EEG if seizure suspected

•+/- Lumbar Puncture if CNS infection suspected

Altered LOC... Management

•Secure airway if GCS < 8

•Give O2 if hypoxic (unless end stage COPD)

•Correct any metabolic conditions

•Treat infection if present

•Reverse toxins

•Consider Naloxone if opioid suspected

•Manage ICP

Glasgow Coma Scale

used to assess LOC in patients with acute brain injury, trauma, stroke, or altered mental status.

It scores eye opening, verbal response, and motor response. The total score ranges from 3 to 15.

Total Score and Severity: GCS

Document each component E+V+M

13-15: Mild brain injury

9-12: Moderate brain injury

≤8 Severe brain injury (secure airway)

coma caused by

caused by lesions that affect both cerebral hemispheres OR the brainstem reticular activating system.

1. Supratentorial causes

2. Brainstem lesions (infratentorial)

3. Diffuse encephalopathies

supratentorial causes of coma characteristics

usually progress in an orderly manner and cause coma by eventually compressing the midbrain and upper brainstem

brainstem lesions may cause coma _______

may cause coma abruptly

Coma: Supratentorial Causes

•Subdural hematoma

•Epidural hematoma

•Cerebral contusion

•Intracerebral hemorrage

•Brain abcess (rare)

•Cerebral infarction (stroke)

•Brain tumor

Coma: Infratentorial Causes

•Basilar artery thrombosis

•Pontine hemorrhage

•Cerebellar hemorrhage or infarction

Coma: Diffuse Encephalopathies Causes

•Meningitis & encephalitis

•Subarachnoid hemorrhage

•Hypoglycemia

•Global cerebral ischemia

•Drug intoxication

•Hepatic encephalopathy

•Hyperosmolar states

•Hyponatremia

•Hypothermia

•Hyperthermia

•Seizure*

Approach to the Comatose Patient

1. ABCs

2. Priority labs

3.I V: dextrose, thiamine, naloxone

4. Treat seizures

5. Full history (family) & neuro exam

6. Head CT if indicated

7. Consider: LP, EEG, MRI

priority labs for comatose pt

-Glucose

-Electrolytes

-ABG

-Liver, thyroid fn

-CBC

-Tox screen

-PT,PTT

Coma PE: eyes

-Funduscopic

-Pupils

-Oculocephalic reflex (doll's eyes)

-Oculovestibular reflex (cold calorics)

-Corneal reflex

Oculocephalic reflex

doll's eyes movement assessing brainstem functioning

brainstem function and oculovestibular reflex

The reflex is independent of the cerebral cortex

Presence of OVR indicates intact brainstem

Oculovestibular reflex (cold calorics)

Used in comatose patients or neurologic exams: Cold water irrigation of the ear → Eyes deviate toward the irrigated ear

(No fast corrective phase in coma)

Coma PE: Posturing and responses to pain, Breathing patterns

Posturing and responses to pain:

–Decorticate

–Decerebrate

–Flaccidity

Breathing patterns

Decorticate posturing

arms flexed toward chest, wrists and fingers flexed, legs extended and internally rotated

Decerebrate posturing

extensor posturing arms extended, adducted and internally rotated, wrists pronated, legs extended and plantar flexed, neck extended

Flaccidity

reduced or absent muscle tone, often seen in certain neurological conditions (e.g., damage to motor nerves, spinal cord injury, or some forms of paralysis)

Flaccid muscles feel limp and offer little resistance to movement.

Syncope

The transient loss of consciousness with spontaneous recovery that results from an acute global reduction in cerebral blood flow.

Syncope is a symptom; the goal is to determine the cause.

3 major types of syncope

orthostatic

cardiac

neurocardiogenic

Differential Diagnoses

•Seizures

•TIA

•Substance use

•Sleep disturbances/Narcolepsy

•Head trauma

•Somatoform disorders

Syncope Causes - Orthostatic

Hypovolemia, vasodilator medications autonomic neuropathies (DM, Parkinson's), pheochromocytoma

Syncope Causes - Cardiac

Arrhythmias, bradycardia, tachycardia, reduced cardiac output, left ventricular flow obstruction (aortic stenosis, hypertrophic cardiomyopathy),PE, pulmonary hypertension, MI, cardiac tamponade, sick sinus syndrome, AV block, V tach or V fib, Mitral stenosis, Long QT syndrome, pacemaker dysfunction

Syncope Causes - Neurocardiogenic

vasovagal, situational (acute hemorrhage, cough, sneeze, anxiety), Valsalva, POTS, hyperventilation

Vasovagal Syncope

ages? physiology?

•"Fainting"

•Common in all age groups

•Physiology: hypotension, vasodilatation & bradycardia due to withdrawal of sympathetic tone and increase in vagal tone

Vasovagal Syncope - Common precipitants

-Prolonged standing

-Warm environments

-Emotional distress

-Pain

Vasovagal Syncope - Pro Drome

-Diaphoresis

-Pallor

-Nausea

-Dim vision

-Salivation

-ringing ears

-Difficulty thinking

Other Reflex Syncope: Situational and Carotid Sinus Sensitivity

•Situational:

-Cough

-Micturition

-Defecation

•Carotid Sinus Sensitivity (overreaction of a "pressure sensor" in your neck like when shaving)

Orthostatic Hypotension causes

•Autonomic dysfunction -- ANS is not regulating BP. sympathetic "fight of flight" system overreacts; blood vessels constrict too much

•Massive hemorrhage

•Severe dehydration

Cardiac Causes of Syncope - Bradyarrhythmias

- Sinus node dysfunction

- 2nd and 3rd degree AV block

- Drugs (beta blockers, Ca channel blockers, digoxin...)

- Pacemaker malfunction

Cardiac Causes of Syncope - Tachyarrhythmias

SVTs more likely to cause pre-syncope & palpitations

Ventricular arrhythmias:

•Ventr. Tachycardia

•Torsades de pointes

•Ventr. Fibrillation

•Long Q-T syndrome

•Brugada syndrome 

Cardiac Causes of Syncope - Outflow obstructions

exertional symptoms are common

-Aortic stenosis

-Hypertrophic cardiomyopathy

Cerebrovascular Causes of Syncope (uncommon)

•Takayasu's disease

•Vertebrobasilar insufficiency

•Subclavian steal syndrome

•Subarachnoid hemorrhage

Takayasu disease

stress cardiomyopathy: preceded by an intense emotional, physical or psychologic stress causing ballooning of the left ventricle. Can be caused by excessive coronary vasoconstriction or increase catecholamine release.

Subclavian steal syndrome

occlusion or severe stenosis of the proximal subclavian artery leading to decreased flow of the ipsilateral vertebral artery

Syncope: Diagnosis

History is essential

-Past Medical History

-Prodrome

-Duration/description of event

-After the event

Physical Exam: incl HEENT, CV, pulm, abd, neuro

Tests

Syncope: Physical Exam... signs

1. Vitals

2. General Appearance

3. Skin

4. HEENT

5. Cardiac/vascular

6. Pulmonary

7. Abdominal

8. Neuro

VS: hypotension ox sats, temp

GA: LOC, signs of trauma, signs of intoxication or withdraw

Skin: skin abrasions or ecchymosis turgor, edema, cap refill, (think volume status/dehydration)

HEENT: any signs of trauma, conjunctiva, pupils, mucus membranes

Cardiac: JVD, displaced PMI (think tamponade, HF, cardiomyopathy) murmurs, rhythm, extra heart sounds,

Vascular: peripheral pulses, carotids

Pulm: crackles, breath sounds (unequal: pneumothorax)

Abd: tenderness, pulsatile mass, signs of GI bleed

Neuro: Mental status, cranial nerves, motor strength and tone, sensation, reflexes, signs of focal deficits

Syncope:Diagnostic Tests

-ECG

-Echocardiogram

-Holter (or other) monitors-inpatient cardiac monitoring for some.

-Tilt table testing

vasovagal syncope treatment overview

-Education

-Maneuvers

-Meds (beta blockers, midodrine)

cardiac syncope

-Varied, depends on the etiology.

- Referral to Cardiology

A patient has the following GCS components:

Eye opening to voice, Inappropriate words, Localizes to pain. What is the total GCS score?

A.9

B.10

C.11

D.12

3

5

5

= 11 (moderate)

Which of the following statements best defines syncope?

A.Loss of consciousness caused by seizure activity

B.Sudden LOC lasting > 30 minutes

C.LOC with persistent neurologic deficits

D.Transient LOC due to global cerebral hypoperfusion

D. Transient LOC due to global cerebral hypoperfusion