Loss of consciousness

1
Loss of consciousness

• ???? ???? ??? ?????
• ??? ???? ????? ?????

2
(No Transcript)
3
(No Transcript)
4
Definition

• Consciousness
• awareness of self and environment.
• In respect of age and developmental level.
• Has two dimension wakefulness and awareness.
• Awareness require wakefulness but.
• wakefulness Brain stern, thalamus ,
  Hypothalamus
• Awareness Cortical neuron
• Crying when hungry means awareness of self.
• Soothing to mothers voice means awareness of
  environment.

5
Definition

• Uncon. Physiologic (Sleep) or pathologic (Coma)
• State of reactivity differentiate them (with
  appropriate stimulus can be aroused )
• Coma unresponsive to pain
• Stupor responsive only to pain
• Obtundation responsive to stim. other than
  paindecreased interest to env. Slower
  reactivity
• Lethargy difficult to maintain arousal state
• Confusion inattentiveness , disorientation
• Hallucination sensory input that is not present
  
• Illusion misinterpreting

6
Definition

• Delirium increased excitability restless ,
  confused hallucination ,agitation metabolic
  ,toxic, infection, epilepsy, night terrors.
• Lethargy decreased excitability
• mass , IICP
• Delusion incorrect thought

7
Definition

• Vegetative state wakefulness without cognition
  ,eyes-open uncons. , incontinence With
  sleep-wake cycle and vegetative function,
  preserved cranial nerve reflexes
• Causes Trauma , infection , degenerative ,
  developmental

8
Definition

• Brain death permanent absence of brain and brain
  stem function ,comatose , apnea , absent brain
  stem reflexes.
• Lack of responsiveness also in
• Locked in syndrome , botulism can process
  information but can not response , dysfunction of
  motor response

9
Definition

• Encephalopathy two of three.
• altered states of consciousness .
• seizure
• altered cognition or personality
• Encephalitis Encephalopathy with CSF
  pleocytosis

10
Glasgow coma scale

• Eye opening 1- 4
• pain not to face ,to any sound .
• Verbal response 1- 5
• If intubated assigned as T
• Motor response 1- 6
• Nail bed pressure response
• Widrawal , flexion , extension .none
• Another stim.on trunk or head
• In paralysis ,arm trauma , spinal inj. Is not
  useful
• Both side

11
Glascow coma scale modification for infant

• eye opening
• Spontaneous 4
• To speech 3
• To pain 2
• None 1

• VerbalSmile, follow, fixes 5Cries but
  consolable 4Persistent irritability 3Moans
  2none
  1

12
Glascow coma scale modification for infant

• Motor
• Obeys , spontaneous movement 6
• Localize pain , withdraws to touch 5
• Withdraw to pain
  4
• Abnormal flexion
  3
• Abnormal extension
  2
• None
  1

13
EVALUATION 

• Coma is a medical emergency whose evaluation
  requires a rapid, comprehensive, and systematic
  approach

14
Etiology

• Structural
• Trauma
• Neoplasm
• Vascular
• Abscess
• Hydrocephaly
• Nonstructural

15
Etiology

• Hypertension
• Hyper ammonia
• Uremia
• Acidosis
• Seizure
• Migraine
• conversion

• Metabolic or Toxic
• Hypoxia ischemia
• Toxin drugs
• Infection
• Hypoglycemia
• ?Na . ? Ca. ? Mg
• Keoacidosis

16
Management

• Stabilization
• ABC
• History
• Rapid neurologic exam.
• Treat treatable toxic or metabolic d.
• Determine level of CNS function and cause

17
Rapid neurologic exam

• Is there intra cranial progressive process.
• Trauma
• Scalp , Fontanel ,Retinal h.
• focal neu.
• Pupil asymmetry in size response, Motor r.
• Brain stem dys
• Respiratory p., corneal r., oculocephalic r.
• IICP
• CT , intubation , hyperventilation

18
IICP

• Hx. of headache , vomiting , ataxia
• Unilateral fixed dilated pupil
• Uncal herniation
• Cushing triad
• ?BP , ?PR , irregularity of res.
• Decerebrate posturing
• Abducent palsy

19
Respiratory p

• Cheyne stokes r. ? diancephalon
• CNH ? Mid- brain
• Apneustic breathing ? pones
• Ataxic breathing ? medulla

20
Treatable toxic or metabolic

• Glucose 0.5 gm /kg
• Naloxan 0.1 mg /kg

21
History

• Medical hx. CHD , Diabetes . Seizure .
• Sudden sei. ICH
• Ataxia , sleepy Drugs
• Fever
• Headache
• Trauma

22
General physical examination

• ? Tem. PR . RR. BP
• Skin rush , color, bruises , nevi .
• Odor
• Meningeal signs
• Optic fundi
• Cardiac
• Abdomen

23
physical examination

• Hemispheric or brain stem
• Anatomic or metabolic
• Pupil Size , Reactivity( 2 ,3)
• Eye movement
• Respiratory pattern
• Motor response

24
physical examination

• Pupilary reflex
• preserved in metabolic..
• Absence suggest structural ..
• Except drug effect
• Anticholinergic ? fix dilated
• Uncal herniation ? unilateral fix dilated 3
• Ipsilateral miosis ? hypothalamic damage
• Mid sized fix ? midbrain
• Pin point ? pontine lesion

25
physical examination

• Eye movement
• Tonic lateral deviation ? seizure in
  contralateral or lesion in ipsilateral
  hemisphere
• Positive oculocephalic ? absens of cortical
  input and intact brain stem.( deviate in opposite
  direction of head)

26
physical examination

• Motor system
• Position , Spontaneous movement , to pain
• Hemiplegia ? contra lateral hem. Or ipsilateral
  spinal
• Hypotonia ? bilateral hem. , medulary or spinal
  inj.
• Decorticate posture ?hemis.dysfunction and intact
  brain stem
• Decerebrate posture ? brain stem compression or
  sever metabolic dis.

27
Diagnostic testing

• BS ,Na , K , Ca , Mg , ABG .
• BUN , Cr.
• liver function test , ammonia .
• CBC, B/C , U/A , U/C ,
• CSF
• Metabolic Endocrine
• CT , MRI
• EEG

28
treatment

• Oxygenation
• Maintain circulation
• Administer glucose
• Consider antidotes
• Reduce ICP 2/3m. ,position, hyperv. , manitol
  ,dexa., lasix
• Stop seizure
• Treat infection
• Correct acid base electrolyte imbalance
• Adjust body tem.
• Manage agitation

29
100 ???1
????? ?? ???? ?? ?? ????? ?? ???
30
101 ??? 10
??? ?? ?? ???? ???? ?? ??? . ?? ???????? ???? ???
? ????? ?? ?? ??? ????? ??????.
31
102 ???100
?? ??? ????? ?? ???????? ?????? ?? ??? ?? ? ????
????? ???? ????? ???? .
32
103 ???????1
?? ??? ?? ??????? ??? ??????. ??? ?? ??? ?????
?? ?????? ?? ?? ??? ???? ?? ????? ?????
33
104 ???????10
??? ???? ?????? ??? ??? ??? ??? ?????? ???? ??
?? ??????.
34
105 ???????100
?? ??? ????? ????? ??????? ?????? ???? ?????? ???.
35
106 ???????1000
??? ?????? ?? ????? ???????
36
107 ???????10000
?????? ????? ???? ? ???? ?? ??????? ?????
37
108 ???????100000
???? ???? ?? ?????? ??? ?????
38
109 ?????? ???????1
???? ? ???? ???? ??? ???
39
1010 ?????? ???????10
????? ?? ???? ??? ??? ????
40
1011 ?????? ???????100
?????? ? ????? ???? ? ????
41
1012 ??????? ???????1
??????? ???? ??? ?????? ???? ? ???? ? ?????
42
1013 ??????? ??????? 10
?? ??? ????? ?? ?? ?????? ?????? ???? ? ???????
??????? ?? ?????? ????
43
1014 ??????? ??????? 100
?????? ???? ???? ?? ???? ??? ?? ???
44
1015 ??????? ???????1
?????? ????? ????? ?? ??? ???????? ????? ???
45
1016 ??? ????1
?? ????? ?? ??? ???? ????? ?????? ????? ???? ???
46
1017 ??? ????10
???????? ?? ??? ??? ?? ?? ???
47
1018 ??? ????100
??? ??? ... ??? ???? ?? ??? ? ????
48
1019 1000 ??? ????
?? ??? ????? ?? ???? ?????? ??? ???? ?? ????
49
1020 ??? ????10,000
?????? ??? ?? ?? ???? ?????? ??? ???? ????? ??
????
50
1021 ??? ????100,000
???? ???? ?????? ?? ??????? ?????? ??? ????
51
1022 ?????? ??? ????1
?? ??? ????? ???? ?? ???????? ??? ??????? ?
?????? ??? ???? ?? ??????
52
1023 10 ?????? ??? ????
?? ??? ????? ??? ???????? ?? ????? ??????? ????
??? ???? ????? ???? ???? ?????. ? ?????? ??????
?? ????? ???? ???? ???? ??? . ???? ?? ?? ????? ??
???????
53
1022
54
1021
55
1020
56
1019
57
1018
58
1017
59
1016
60
1015
61
1014
62
1013
63
1012
64
1011
65
1010
66
109
67
108
68
107
69
106
70
105
71
104
????? ?? ?? ??? ?? ????? ?? ?? ????? ? ?? ???
?? ???? ? ?? ??? ???? ??? ?
72
103
? ?? ??????? ?? ???? ?? ??? ???? ????? ?
73
102
74
101
??? ??? ??? ?? ??? ???? ???? ???? ??????
75
100
?? ??? ???? ?????? ???? ?? ???????? ??? ?? ??
??? ??? ??? ????
76
10-1 ????? ???10
?? ??? ????? ???????? ?? ????? ??? ?? ??????.
77
10-2 ????? ???1
?? ??? ????? ??? ???????? ?????? ?? ??? ?? ??????
??????
78
10-3 ???????1
?????? ????? ??? ???? ?? ????? ?????
79
10-4 ??????100
?????? ???? ???? ??? ??? ?? ?????? ????? ??? ????
?? ??????
80
10-5 ??????10
???? ?? ???? ????
81
10-6 ??????1
???? ?? ???? ???? ???? ?????? ???
82
10-7 1000 ????????
???????? ???? ?????? ???? ?? ??? ??????. ?? ??
??? ?????? ??? ??? ??????? ???????? ?? ?? ??????
83
10-8 ????????100
?? ??? ?????? ????? ??? ?????? DNA ????
?????? ???
84
10-9 10 Angstroms
???? ?? ??????? ???????? ?? ???? ?????? ???.
85
10-10 ????????1
???? ?? ????? ???? ?? ????????? ?? ????. ??? ???
????? ?? ???? ?? ?? ??? ???? ???. ??? ????????
????? ???? ?????????? ?? ???? ?????????? ??
?????? ??????.
86
10-11 10 picómeters
?? ??? ????? ???? ?????? ?????????? ?? ??? ??? ??
?????? ????
87
10-12 1 Picómeter
???? ???? ????? ???? ??? ???? ? ???? ???????
88
10-13 100 Fentómeters
?? ??? ?????? ???? ?????? ? ????? ??? ?? ??
?????? ???? ??? ?? ?????? ??????
89
10-14 10 Fentómeters
????? ??? ?? ?????? ???? ??? ??? ???? ?? ??????
90
10-15 1 Fentómeter
????? ?? ?? ????? ????? ?? ??? ????? . ???? ????
???? ??????
91
10-16 100 Atómeters
Examine the quark partícules ???? ??????? ?????
??? ?????? ???? ???? ????