Altered Level of Consciousness
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The document discusses altered levels of consciousness. It defines consciousness and covers a spectrum from consciousness to coma. It describes states of lethargy, stupor/obtunded, and coma. Coma is defined as a state of unconsciousness where a person cannot be aroused. Other altered states like akinetic mutism and persistent vegetative state are also described. Potential causes of altered consciousness including structural issues, functional problems, metabolic derangements, drugs, toxins, and others are outlined. The assessment, investigations, treatment and management of patients with altered consciousness are discussed in detail.
Altered Level of Consciousness
- 1. Altered level of Consciousness Ms Tarika Sharma Assistant Professor MMCON, MMU
- 2. 2 of 19 The level of responsiveness and consciousness is the most important indicator of the patient’s condition. Consciousness is defined as being awake and aware of both one’s self and one’s surroundings, OR it is the human awareness of both internal and external stimuli. Introduction
- 3. 3 of 19 Altered Consciousness covers a spectrum of states: Consciousness Lethargy Stupor or Obtunded Coma Continuum Introduction Consciousness Coma
- 4. 4 of 19 Lethargy: Mild depression in level of consciousness and can be aroused with little difficulty. Obtund : More depressed level of consciousness and can not be fully aroused.( slow response and sleepiness) Stupor : Can not be aroused from a sleep like state. (only respond by painful stimuli) Coma: More depressed level of consciousness and unable to make any purposeful response. Introduction
- 5. 5 of 19 Coma Derived from the Greek word ‘Koma’ or deep sleep Coma is a clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or even years). It is an alteration of consciousness in which a person appears to be asleep, cannot be aroused even by painful stimuli, and shows no awareness of the environment.
- 6. 6 of 19 Akinetic mutism It is a state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes.
- 7. 7 of 19 Persistent vegetative state Is a condition in which the patient is described as wakeful but devoid of conscious content, without cognitive or affective mental function.
- 8. 8 of 19 Inability to move or respond except for eye movements due to a lesion affecting the pons. Locked In Syndrome
- 9. 9 of 19 Cranial Causes: Structural CNS infections Mass lesions CSF obstruction + ↑ volume Trauma Functional Seizures Hypoxic - ischemic injury Etiology
- 10. Etiology Systemic shock hypo/ hypernatremia hypoglycemia diabetic coma hepatic uremic hypoxia Respiratory failure Acidosis/ alkalosis Extracranial causes Metabolic
- 11. Etiology Barbiturates benzodiazepines Opioids antihistamines Iron Salicylates Extracranial causes Drugs
- 12. Etiology Lead CO poisoning pesticides alcohol/ ethylene glycol Extracranial causes Toxic
- 13. Etiology Endocrine hypothyroidism diabetes Miscellaneous hypertensive encephalopathy heat stroke hypothermia Extracranial causes
- 14. 14 of 19
- 15. 15 of 19 Normal consciousness is maintained by integrity of certain areas of the cerebral cortex, thalamus and brain stem Altered consciousness due to: Diffuse insult to both cerebral hemispheres (metabolic/toxic/hypoxic/ischemic) or focal lesion affecting ascending reticular activating system (ARAS) located in upper pons, midbrain & diencephalon. Affected by compression (herniation) Pathophysiology
- 16. 16 of 19 Pathophysiology Underlying cause Disruption in the cells of the nervous system, neurotransmitters, or brain anatomy. Results in faulty impulse transmission, impeding communication within the brain or from the brain to other parts of the body.
- 17. 17 of 19 The level of responsiveness and consciousness is the most important indicator of the patient’s condition. Level I-conscious, cognitive, coherent (3 C’s) Level II-confused, drowsy, lethargic, obtunded, somnolent Level III-stuporous;responds only to noxious, strong or intense stimuli, e.g sternal pressure, trapezius pinch, pressure at the base of the nail or supraorbital area;very strong light or very loud sound. Level of Consciousness
- 18. 18 of 19 Level IV =Light coma-response is only by grimace or withdrawing limb from pain; primitive and disorganized response to painful stimuli. =Deep coma-absence of response to even the most painful stimuli. Level of Consciousness…
- 19. 19 of 19 Circumstances? Duration & onset? Acute in CNS infection, trauma, seizure, poisoning, metabolic, vascular H/o poisoning? H/o trauma? H/o fever? H/o seizure? Past medical history H/o seizures in the past? H/o known endocrine disorder? H/o headache/vomiting/visual symptoms? Quick History & Examn
- 20. 20 of 19 Vitals Fever BP S/o shock S/o ↑ ICP bradycardia, hypertension Respiration rapid in acidosis & CNS lesions also General Physical: Evidence of trauma, injury, tongue bite Jaundice Breath - for odor of ketones, fetor hepaticus etc Skin peticheae, exanthem Moist skin with ↑salivation in organophosphorus poisoning Complete systemic exam Quick History & Examn
- 21. 21 of 19 The goal of neurologic examination are: To determine depth of coma. To localize the process leading to coma. Includes Level of consciousness (Glasgow coma scale) Pupillary responses Eye movements(spontaneous or induced) Motor response Meningeal signs Sign of increased ICP Neurological Examn
- 22. 22 of 19 ACTIVITYACTIVITY BEST RESPONSEBEST RESPONSE Adults/Older ChildrenAdults/Older Children Infants ( modified GCS )Infants ( modified GCS ) ScoreScore Eye OpeningEye Opening ( E )( E ) 1.1. SpontaneousSpontaneous 2.2. To speechTo speech 3.3. To painTo pain 4.4. NoneNone 1.1. SpontaneousSpontaneous 2.2. To speechTo speech 3.3. To painTo pain 4.4. NoneNone 44 33 22 11 VerbalVerbal ( V )( V ) 1.1. Appropriate speechAppropriate speech 2.2. Confused speechConfused speech 3.3. Inappropriate wordsInappropriate words 4.4. Incomprehensible orIncomprehensible or none specific soundsnone specific sounds 5.5. NoneNone 1.1. Coos, babblesCoos, babbles 2.2. Irritable, cries butIrritable, cries but consolableconsolable 3.3. Cries, inconsolableCries, inconsolable 4.4. Moans to painMoans to pain 5.5. NoneNone 55 44 33 22 11 MotorMotor ( M )( M ) 1.1.Obeys commandsObeys commands 2.2.Localizes painLocalizes pain 3.3.Withdraws to painWithdraws to pain 4.4.Decorticate to painDecorticate to pain 5.5.Decerebrate to painDecerebrate to pain 6.6.NoneNone 1.1. Normal spontaneousNormal spontaneous movementmovement 2.2. Withdraws to touchWithdraws to touch 3.3. Withdraws to painWithdraws to pain 4.4. Decorticate to painDecorticate to pain 5.5. Decerebrate to painDecerebrate to pain 6.6. NoneNone 66 55 44 33 22 11 Glasgow coma scale
- 23. 23 of 19 Size and reactivity of pupils Pupils Lesion/Dysfunction Pinpoint Pons, opiates, cholinergic intoxication Mid position – fixed or irregular Midbrain lesion Unilateral , dilated and fixed Uncal herniation Bilateral , dilated and fixed Diffuse damage, central herniation, global hypoxia ischemia, barbiturates, atropine
- 24. 25 of 19 Eye movements
- 25. 26 of 19 Motor response
- 26. 27 of 19 Meningeal signs
- 27. 28 of 19
- 28. 29 of 19 The signs of raised ICP includes: 1- abnormal respiratory pattern. 2- unequal or unreactive pupils. 3-impaired or absent oculocephalic or oculovestibular responsees. 4- systemic hypertension, bradycardia. 5- tense fontanelle. 6- abnormal body posture or muscle flaccidity. S/o ↑ICP
- 29. 30 of 19 Blood: CBC, clotting and bleeding time Glucose, electrolyte, urea, liver function test, ammonia, and lactate Toxocology: Urine, blood,gastric aspirate for ingestion Acid-base: ABG Investigations
- 30. 31 of 19 Microbiology: Blood and urine cultures Imaging: CT , MRI Lumbar puncture – CI if ↑ICP. Abnormal in CNS infections Investigations
- 31. 32 of 19 Coma is an acute life-threatening neurological emergency Requires prompt intervention for preservation of life & brain function So the ABC are the initial priority Immediate Management
- 32. 33 of 19 A – airway prevent tongue falling back, suction B – breathingrespiratory support, oxygen C- circulationiv fluids, monitor BP, vasopressors If any evidence of poisoning GL Immediate Management
- 33. 34 of 19 ABCs: Intubate if GCS ≤8 or respiratory failure Stabilize cervical spine Supplement O2 IV access Blood pressure support as needed Dextrose 0.25 g/kg (2.5 mL/kg of 10 % dextrose solution) Treat definite seizures. Lorazepam (0.1 mg/kg, maximum single dose 5 mg). If seizures continue treat as for status epilepticus. Treatment
- 34. 35 of 19 Infection: Ceftriaxone 100 mg/kg (maximum single dose 2 grams) and Vancomycin Acyclovir Ingestion: Naloxone 0.1 mg/kg IV; maximum 2 mg IV (use if opioid toxidrome: miosis, respiratory depression, hypotonia) Increased ICP: Mannitol 0.5 - 1 gram/kg IV Treatment
- 35. 36 of 19 Complications Respiratory failure Pneumonia Pressure ulcers, and Aspiration.
- 36. 37 of 19 Check LOC of patient using GCS. Determining the patient’s orientation to time, person, and place assesses verbal response. The patient is asked to identify the day, date, or season of the year and to identify where he or she is or to identify the clinicians, family members, or visitors present. Other questions such as, “Who is the president?” or “What is the next holiday?” Nursing Assessment
- 37. 38 of 19 Ineffective airway clearance related to altered level of consciousness. Risk of injury related to decreased level of consciousness Deficient fluid volume related to inability to take in fluids by mouth Impaired oral mucous membranes related to mouth breathing, absence of pharyngeal reflex, and altered fluid intake Risk for impaired skin integrity related to immobility Impaired tissue integrity of cornea related to diminished or absent corneal reflex Nursing Diagnosis
- 38. 39 of 19 Ineffective thermoregulation related to damage to hypothalamic center Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control Bowel incontinence related to impairment in neurologic sensing and control and also related to transitions in nutritional delivery methods Disturbed sensory perception related to neurologic impairment Interrupted family processes related to health crisis Nursing Diagnosis
- 39. 40 of 19 Thank You!
Editor's Notes
- #26: Vestibulo ocular reflex