ACUTE CONFUSIONAL STATES AND COMA

Confusional states and coma are among the most common problems in general medicine. It is estimated that over 5% of admissions to the emergency ward of large busy hospitals are due to diseases that cause a disorder of consciousness. These conditions can take the form of drowsiness, stupor or coma.

UNDERSTANDING THE MECHANISM OF COMA

Consciousness or alertness is maintained by brainstem and thalamic neurons, the reticular activating system and it’s connections to the cerebral hemispheres.

therefore structural brainstem and thalamic lesions bring the patient more likely into coma compared to supratentorial (cerebral) lesions.

STRUCTURAL LESIONS

are responsible for about 35 % of causes of coma, e.g. - CVA - Head injuries - Brain tumors - SAH

METABOLIC CONDITIONS: affect the brain globally and constitute about 65 % of causes e.g.
* DKA * Hyperosmolar coma * Hypoglycemia * Hepatic coma * Uremia * Hyponatremia <115 meq/L * Hypercalcemia

OTHER CAUSES:
             

Post ictal state Cardiac Respiratory Hypocalcemia Septicemia Encephalitis Meningitis Wernick’s encephalopathy Vitamin B12 deficiency Heat stroke Hypothermia Myxoedema Drug overdose Organophosphorous poisoning

APPROACH TO THE PATIENT
 

HISTORY LIFE THREATENING CONDITIONS SHOULD BE ATTENDED FIRST:
 

ABC CONSIDER GIVING: - Oxygen - D50 - Naloxone - Thiamine - Few drugs have antidotes - Treat arrhythmias - Give fluids if indicated

ASSESS:
         

Temperature Blood pressure Breathing & respiration Pupillary reactions Fundoscopy Level of consciousness Using the AVPU or GCS Localizing signs Patient should be nursed on the semiprone position Correct hypothermia and hyperthermia

 THE IDEA IS TO PREVENT FURTHER BRAIN DAMAGE.
 WHEN

LABORATORY INVESTIGATIONS ARE AVAILABLE CORRECT HYPERCALCEMIA AND ELECTROLYTE DISTURBANCES.

LABORATORY INVESTIGATIONS:
           

CBC RBS RFT LFT URINALYSIS & CULTURE BLOOD CULTURE OSMOLALITY ABG BLOOD GROUP & CROSSMATCHING CHEST X-RAY CT BRAIN LUMBAR PUNCTURE

COMA LIKE SYNDROME:
Psychogenic unresponsiveness  The vegetative state  Brain death

ASSESS BRAIN STEM FUNCTION
    

Corneal reflex The gag reflex Cough reflex The doll’s head maneuver The ice water caloric test

CONSIDER:
  

Basilar artery thrombosis Cerebellar hemorrhage Pituitary apoplexy * thrombotic thearapy for basilar artery thrombosis * urgent surgery for cerebellar hemorrhage and pituitary apoplexy * ventricular puncture for acute hydrocephalus

PROGNOSIS

THANK YOU!
DR. ABDLR MUSTAFA

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