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Consciousness
Consciousness is an active state of arousal and awareness It is a function of the reticular activating system.
Classification
Consciousness is subdivided into: 1. Alertness (arousal) 2. Awareness
Alertness
It is the maintained arousal with intact sleep wake cycle. It is a function of the RAS at the level of brain stem (mesencephlon) and diencephalon (thalamus and hypothalamus). The arousal system act as the switch for the cortical awareness system.
Awareness
It is the higher level of integration of multiple sensory input that allow meaningful understanding of self and environment. It is a function of RAS at the level of interaction with the cortex. The arousal is conditional for awareness however one can be aroused but not aware. Awareness includes all cognitive functions of the brain (e.g. attention, orientation, abstraction, judgement).
Disorders Of Awareness
Bilateral diffuse Cerebral Cortex Failure
Due to disturbance of the RAS at the level of cortex. A state of arousal with impaired awareness Massive or diffuse cortical affection as in 1. Increase ICT (sinus thrombosis, SOL...) 2. Encephalitis 3. Postischemic anoxic (cardiac arrest)
Disorders Of Arousal
Due to affection of the RAS at the diencephalic level, either from a disease primarily affecting this area (disorder of arousal from the start) or a as a progression of disorders of awareness ( start as disorder of awareness then continue as disorder of arousal)
Etiology
Primary brain stem pathology Secondary brain stem injury e.g. herniation
Clinical Approach
History
Rate of onset of coma As a disorder of arousal vs awareness Trauma, Drugs, illness, psychological troubles.
NEUROLOGICAL
Mental Status Examination Type of Respiration Cranial N Examination Motor Function Sensory Function Cranium & spine Stretch signs
Level Of Consciousness
Confused Delerious Vegetative Akinetic mute Lethargy Sleepy Drowsy Stuperous Light coma Deep coma
Psychogenic Unresponsiveness
Motor Response
Normal Response Localizing Flexion (decortication) Abnormal Flexion Extension (Decerebration) No response
Verbal Response
Spontaneous speech Few words Uttering sounds In response to verbal stimuli In response to painful stimuli No response
Eye Response
Sponateous eye opening Eye opening to verbal stimuli Eye opening to painful stimuly No eye opening
Deep COMA
No Motor reponse No Verbal Response No Eye response
Respiratory Patterns
Respiration Cheyne-Stokes Description Localization Bilateral deep hemispheric and basal G dysfunction, upper B st may be affected Periods of hyperventilation gradually diminishing to apnea then build up again - variable duration Central Continuous rapid Neurogenic regular deep Hyperventilation hyperventilation (25/m)
Respiratory Patterns
Respiration Apneustic Breathing (Inspiratory cramp) Description Localization Pontine Damage Prolonged inspiration followed by apnea , or clustered inspiration followed by apnea Ataxic Breathing Chotic breating. In (Gasping) gaspings : gasps followed by apnea of variable duration Depressed Shallow slow Breathing ineffective breathing
Motor Function
Spontaneous (Voluntary/ Involuntary*) / Reflex withdrowal Asymmetric motor response (weakness) Tone (Flaccidity = poor prognosis) Reflexes (Areflexia = poor prognosis) Planter response *Involuntary contractions (mostly epiletic as myoclonic jerks, lid or facial twitches)
SENSORY FUNCTION
Response to noxious stimulus
Meningeal Signs
Neck stiffness ( DD rigidity) Sciatic or femoral stretch signs Upper limb stretch sign
Differential Diagnosis
Locked In State Vegetative State Akinetic Mute state (Abulia) Non Convulsive status epilepticus Psychogenic Unresponsiveness
ETIOLOGY
Onset Disorder of Arousal Brain stem vascular, Traumatic, epileptic Inflammatory Disorder of Awareness Toxic
Dramatic, sudden
Rapid
Slow
SOL
Investigation
Vital Data Stabilization Glucose level Metabolic screening Urgent Ct brain or MRI CSF if needed Toxic screening EEG
Management
1. 2. 3. 4. 5. 6. 7. 8. Immediate Vital Data Stabilization Of the Etiology Care of the comatose: Ventilation Cardiac and fluid balance monitoring Skin care Bowel care Bladder care Eye care Nutrition Restlessness and agitation
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