Transcript 急性昏迷
Acute coma Definition Unconsciousness , Disturbance of consciousness Degression of level of consciousness Deep inhibitory state of higher nervous activity Mechanism Consciousness ① Level of awareness of brain ② Sensation, Perception Himself , Enviroment ③ Responsiveness Inner need, External stimulation ④ Expressed language, Body movement, Behavior Composition of consciousness Cognition Contents ： Orientation, Perceptivity, Attention, Remembrance, Affection, Thinking and Behavior Expressed ： Language,Body movement and behavior Controlled ： Cerebral cortex Waking state Controlled Ascending reticular activating system in brainstem ( ARAS ) Function Special sensory conduction → Unspecial nerve corpuscle in thalamus → All cerebral cortex Etiology and pathology Disturbance ① Cerebral cortex ② Ascending reticular activating system in brainstem or thalamus Feature of Ascending reticular activating system ① Thin nerve fiber ② Longer transmiting distance ③ More times for neurone to be exchange ④ Influenced easily by enviroment and drug Clinical classification Disturbance of consciousness in level Coma, Confusion Special kinds of disturbance of consciousness Dementia, lapsus memoriae Clinical classification of unconsciousness Somnolence Stupor Arousal + + Orientation + Go with examination + Reaction to stimuli Spontaneous action Brainstem reflexes Babinski sign Vital sign Light coma Deep coma - - - - - - + + + - + + + - + + +- - + + +- - stable Stable stable unstable Special group of disturbance of consciousness Confusion Delirium Somnolence + + Irritation - + Orientation + - Attenuation - - Delusion Illusion + +- + + Insight + - Change in autonomic nerve + + Glassgow coma scale Eye Verbal Motor Scores Obeys commands 6 Orientated Localises pain 5 confused Withdraws from pain 4 Eye opening to Inappropriate words speech Flexion to pain (Decorticate) 3 Incomprehe Eye opening to -nsible sounds pain Extension to pain (Decerebrate) 2 No verbal No eye opening response No motor response 1 Eyes opening spontaneously Special groups of conscious disturbance — coma vigil 1) Open and close eyes 2) Chew and swallow 3) Sleep-wake cycles Decorticate syndrome 1) Arms flex ，leg straighten 2) Higher muscular tension 3) Babinski sign 4) Cerebral cortex is damaged Decerebrate syndrom 1) Four limbs straighten 2) Higher muscular tension 3) Babinski sign 4) All brain is damaged Akinetic mutism 1) Muscle relaxation， 2) No babinski sign 3) Ascending reticular activating system in brainstem or thalamus is damaged Differential diagnosis Persistent vegetative state 1) “Unconscious and unaware” 2) Exhibit sleep-wake cycles 3) Grinding teeth, swallowing, smiling, shedding tears, grunting, moaning, or screaming 4) Heads and eyes can track moving objects or turn towards a sound 5) An impaired connectivity between the brainstem, thalamus and the cortex 6) The general brain activity in the cortex is lower in the PVS state. Brain death Complete and irreversible cessation of brain activity (cerebral, brain stem , cerebellum) Criteria 1) Deep coma 2) No spontaneous respiration 3) No response to pain, no cranial nerve reflexes 4) Spinal reflex may persist 5) EEG: flat or isoelectric 24h 6) Exclude for intoxication, hypothermia, metabolic disturbance or persistent vegetative state Hysteria Syncope 1. Transient loss of consciousness and posture 2. A global reduction in blood flow to the brain Locked-in syndrome A lesion of the ventral pons. 1) Alert 2) Unable to response with speech or facial or limb movements 3) Vertical eye movements and blinking Abulia A lesion of both lobus frontalis Serious Apathy Stuporous state Stupor syndrom A rough response ( like screaming ) to a noxious stimulus Etiology Central nervous system diseases Cerebrovascular disease Cerebral thrombosis Cerebral embolism Cerebral hemorrhage Subarachnoid hemorrhage Headtrauma Seizure Inflammation Encephalitis, meningitis, cerebral abscess Tumor Hypoxia Heart -- Cardiac output ↓ Heart failure, Asystole, tachycardia, bradycardia Lung -- pO2 ↓, pCO2↑, acidosis COPD, pneumonia, pneumonedma pulmonary infarction, drowing Liver--hepatic coma Serious hepatitis,hepatonecrosis hepatic cirrhosis Kidney—Uremia Acidosis, ion disturbance or cerebral edema after dialysis Metabolic abnormalities Hypoglycemia, hyperglycemia, Ketoacidosis, hyperosmosis，lactic acidosis hyperthyroidism crisis，Addison‘s disease sheehan syndrome Electrolyte disturbances Low sodium, low chlorine, water intoxication Intoxication Drug： Benzodiazepine, barbiturates, antipsychotic drug Insecticide： Organophosphorus，pyrethroid carbamate pesticide，weed killer Other intoxicant Alcohol, Carbon Monoxide, Organic solvent, poisnous vapor Physical examination General examination Temperature T↑ ：Inflamation, central high fever heat stroke T↓ ：Shock, hypoglycaemia, Hypnotic intoxication Arterial pulse p ↓：Sinus bradycardia, atrial ventricular block(A-VB) ,intracranial hypertension p↑：Hyperpyrexia, hyperthyreosis congestive heart failure, shock supraventricular tachycardia Breath Rhythm Cheyne-Stokes breathing ---- A lesion of Cerebral hemishere Central neuro-hyperventilation ---- A lesion of midbrain Ataxia breathing ---- A lesion of bulbus medullae Smell ---- Rotten apple, garlic, alcohol, amonia, hepatic odor Blood pressure BP↑ ：hypertensive encephalopathy, CH BP↓ ：shock Skin and membrana mucosa Jaundice, bleeding point, ecchymosis, Sweat, cyanosis, flush Cranal trauma Raccon eyes, Battlesign， leakage of cerebrospinal fluid Meningeal irritation sign Kernig sign or brudzinski sign Examination in internal medicine Heart, lung, liver, kidney, etc. Neurologic check Eyes sign Pupil One dilatation：Cerebral hernia Both dilatation：Atropine poisoning Both diminution: Organophosphate，morphine Hypnotic，hypoglycaemia A lesion of brainstem Eyeball position Fixation： Divergence: cerebellum Side-glance： Lesion of side glance centre （ cerebral hemisphere or pons ） Fasciculus longitudinalis mediali Eye ground Bleeding Vitreous hemorrhage Angiosclerosis, Papilledema Pain recation Locating Decorticate rigidity ( thalamus or cerebral hemisphere ), Decerebrate rigidity (midbrain) Assessment Degree of coma Palsy sign Hemiplegia, Babinski sign Brainstem function Corneal reflex Oculovestibular reflex Oculocephalic reflex (Dull head test) Auxiliary examination • CT, MRI , EEG , examination of cerebrospinal fluid • Po2, Pco2, HCO3, BE , CoHb, Hemiglobin, Choline esterase (CHE) GPT,GOT, Blood ammonia , BUN Cr, Ion, Blood glucose Detecting intoxicant or product of metabolism Diagnosis History+Physical sign + Auxiliary examination Onset ：environment, process, time degree of urgency, motivation, etc. Main Age, symptom and concomitant symptom season, past history Treatment Symptomatic treatment 1) Monitor: ECG, BP, Consciousness, pupil pulse, respiration , etc. 2) Open respiratory tract 3) Balance water , electrolytes and acidbase. 4) Relieve and prevent cerebral edema 20% manital, complexglycerine, furosemide , 50%Glucose, Albumin, etc. 5) Protection for cerebral function Radical scavenger：barbiturate, VC,VE Opiate receptor blocking pharmacon: Narcon Ca2+ receptor blocking pharmacon Nimodipine , Flunarizine , etc. 6) Hypothermy, Hibernotherapy: Tympanic temperature: 33~35℃ Etiological treatment Prevent complication Aspirated pneumonia, Urinary system infection, Bedsore, Disturbance of Water-Electrolyte （Hyponatremia） Acid- base balance