דליריום חדש Flashcards
גורמים
תרופות אלכוהול אנדוקריני - היפותירואיד, היפרתירואיד, היפוגליקמיה, היפרגליקמיה אלקטרוליטרי - היפונתרמיה, היפרקלצמיה, היפוקלצמיה חסר תזונתי - אנצפלופתית וורניקה, בי 12 אס"ק - אנצפלופתיה כבדית, כלייתית, פגיעה פולמונרית, השתלת איברים מנינגיטיס, אנצפליטיס גרורות למוח ספסיס וסקולרי - שבץ, דימום סאב ארכנואידי לופוס, וסקוליטיס DIC, TTP חבלת ראש לאחר פרכוס פסיכיאטרי
הרעלת אלכוהול
ניסטגמוס, דיסארתריה, אטקסיה
סיכון לחבלות ראש, היפוגליקמיה
שימוש כרוני - סיכון למנינגיטיס וחסר תזונתי
סכנות בגמילה מאלכוהול כתלות בזמן
Tremulousness & Hallucinations - first few days
Seizures - 1-3 days
Delirium termens - day 3-4
Tremulousness & Hallucinations
self-limited
tremulousness, agitation, anorexia, nausea, insomnia, tachycardia, and hypertension.
visual hallucinations- 25% of patients.
treat: Lorazepam or diazepam IV every 5 to 15 minutes until calm and than hourly
Seizures alcohol withdrawal
from toses with seizures: 40% - single seizure 90% have between one and six seizures. last 6 hours Treatment is not usually required, if prolonged, more than six seizures, status epilepticus, - search for other causes
Delirium Tremens
most serious ethanol withdrawal syndrome
lasts for up to 72 hours.
confusion, agitation, fever, sweating, tachycardia, hypertension, and hallucinations.
Death may result from concomitant infection, pancreatitis, cardiovascular collapse, or trauma. Treatment: lorazepam or diazepam
fluid and electrolyte
beta blocker for hypertension or tachycardia
HYPOTHYROIDISM
- most common cause - Hashimoto thyroiditis
- fatigue, depression, weight gain, constipation, bradycardia, dry skin, and hair loss
- may produce a confusional state, coma, or dementia. 4. dysarthria, deafness, or ataxia,
- most characteristic abnormality - delayed relaxation of the tendon reflexes.
- low serum thyroid hormone, elevated TSH
- CSF pressure & protein - elevated
- Hypothermia, hypoglycemia, hyponatremia, and respiratory acidosis may occur.
——— associated with entrapment neuropathy, especially carpal tunnel syndrome—————–
treatment of severe myxedema
IV levothyroxine and hydrocortisone
HYPERTHYROIDISM
most often - Graves disease
anxiety, palpitations, sweating, and weight loss.
younger patients - agitation, hallucinations, psychosis Old - apathetic and depressed
Neurologic examination - tremor and hyperreflexia
elevated serum T 4 , free T 4 , T 3 and free T 3
low TSH.
HYPOGLYCEMIA - clinical findings
Early signs o- tachycardia, sweating, and pupillary dilation,
Late - confusional state
Signs of brainstem dysfunction - abnormal ocular movements and loss of pupillary reflexes.
Respiratory depression, bradycardia, hypotonia, and hyporeflexia ultimately supervene,
Hypoglycemic coma
focal neurologic signs
focal or generalized seizures.
Hypoglycemia treatment
glucose IV - 50 mL of 50% dextrose
Hyperglycemia clinical findings
blurred vision dry skin anorexia polyuria polydipsia. hypotension Kussmaul respiration mild confusion to coma. Focal neurologic signs seizures
Hyperglycemia - treatment
IV insulin
fluids
K+
antibiotics
Hypoadrenalisem
addison disease
fatigue, weakness, weight loss, anorexia, hyperpigmentation of the skin, hypotension, nausea and vomiting, abdominal pain, and diarrhea or constipation.
Treatment - hydrocortisone and correction of hypovolemia, hypoglycemia, electrolyte disturbances, and precipitating illnesses.
HYPERADRENALISM - Cushing syndrome
clinical findings and cause
exogenous glucocorticoids.
moon facies with facial flushing
truncal obesity, hirsutism, menstrual irregularities, hypertension, weakness,
cutaneous striae, acne, and ecchymoses.
depression or euphoria, anxiety, irritability, memory impairment, psychosis, delusions, and hallucinations.
HYPERADRENALISM - Cushing syndrome
diagnosis
dexamethasone suppression test,
24-hour urine free cortisol level, or late night salivary cortisol assay.
ACTH levels - primary or secondary
MRI - localize pituitary or other ACTH-secreting tumors.
HYPERCALCEMIA causes
primary hyperparathyroidism,
multiple myeloma,
PTH related secreting tumors
Hypercalcemia Symptoms
thirst, polyuria, constipation, nausea and vomiting, abdominal pain, anorexia, and flank pain from nephrolithiasis.
above 8.5 mEq/L - headache, weakness, and lethargy.
Seizures are rare.
short QT interval
Hypocalcemia symptoms
irritability, delirium, psychosis with hallucinations, depression, nausea and vomiting, abdominal pain, and paresthesias of the circumoral region and distal extremities. Chvostek sign Trousseau sign Seizures - life-threatening. 4.5 mEq/L) prolonged QT interval.
WERNICKE ENCEPHALOPATHY - causes, pathology
usually a complication of chronic alcoholism
malnutrition - cancer, after bariatric surgery.
deficiency of thiamine (vitamin B 1 ).
neuronal loss, demyelination, and gliosis in periventricular gray matter.
Proliferation of small blood vessels and petechial hemorrhages may be seen.
medial thalamus, mammillary bodies, periaqueductal gray matter, cerebellar vermis, and oculomotor, abducens, and vestibular nuclei.
WERNICKE ENCEPHALOPATHY - clinical findings
ophthalmoplegia, ataxia , and confusional state.
opthalmo - nystagmus, IV pulsy, gaze palsy (horizontal & vertical)
Hypothermia and hypotension may occur - hypothalamic involvement.
macrocytic anemia,
MRI - atrophy of the mammillary bodies
WERNICKE ENCEPHALOPATHY - treatment
thiamine
opthalmoplegia and atazia resolve after 1 day
ataxia - 1 month
VITAMIN B 12 DEFICIENCY
peripheral neuropathy, corticospinal tracts and dorsal columns, nutritional amblyopia (visual loss), cognitive dysfunction macrocytic anemia. main cause - pernicious anemia , a defect in the production of intrinsic factor associated with atrophic gastritis, anti-parietal cell antibodies, and achlorhydria, gastric resection and vegan diet.
B12 clinical findings
Distal paresthesias, gait ataxia, a bandlike sensation of tightness around the trunk or limbs, and Lhermitte sign (an electric shock–like sensation along the spine precipitated by neck flexion)
low-grade fever, glossitis, lemon-yellow discoloration of the skin, and cutaneous hyperpigmentation.
Associated peripheral nerve involvement may cause loss of tendon reflexes in the legs and urinary retention.
B12 - lab
macrocytic anemia
leukopenia
hypersegmented neutrophils
thrombocytopenia
Schilling test
determines whether defective intestinal absorption of vitamin B 12 (as in pernicious anemia) is the cause of B12 deficiency
HEPATIC ENCEPHALOPATHY
cause, symptoms, lab
complication of cirrhosis, portosystemic shunting, chronic active hepatitis, hepatic necrosis after viral hepatitis.
ammonia and other toxins diffuse into the brain
Symptoms - nausea, anorexia, and weight loss. GI bleeding, agitation, and coma.
asterixis - a flapping tremor of the outstretched, dorsiflexed hands or feet
LAB - elevated bilirubin, transaminsae, PT, PTT, respiratory alkalosis
CSF - elevated glutamine - most specific!!!
HEPATIC ENCEPHALOPATHY - treatment
underlying cause vitamin E FFP rifaxamin - antibiotic that reduces ammonia-forming bacteria in the colon lactulose
UREMIA Renal failure
may produce encephalopathy
hyperventilation
motor manifestations.
seizures and focal neurologic signs are common,
Laboratory - elevated urea, creatinine, and potassium, and metabolic acidosis,
EEG - diffusely slow and may show triphasic waves or paroxysmal spikes or sharp waves.
management - treat the cause.
hydration, protein and salt restriction, and treatment of complications such as seizures.
Dialysis itself can produce an encephalopathy
POSTINFECTIOUS ENCEPHALOMYELITIS
immune-mediated demyelinating disorder
1 month after a bacterial or viral infection or vaccination. Clinical features include confusion or coma and focal neurologic deficits
- acute disseminated encephalomyelitis -
MRI -multifocal demyelinating lesions
CSF may show lymphocytic, polymorphonuclear pleocytosis. - Bickerstaff brainstem encephalitis
similar but affects the brainstem and cerebellum - acute hemorrhagic leukoencephalitis (high mortality!), MRI -bihemispheric demyelinating lesions associated with hemorrhage and edema,
CSF - may contain red blood cells.
Treatment - methylprednisolone 3 to 5 days, followed by prednisone 4 to 6 weeks.
SEPSIS-ASSOCIATED ENCEPHALOPATHY
impaired cerebral blood flow, BBB disruption cerebral edema. Gram-negative CSF examination - exclude meningitis. EEG abnormal. supportive treatment Mortality is high, but can be reduced by prompt diagnosis and treatment.
HYPERTENSIVE ENCEPHALOPATHY
A sudden increase in blood pressure,
develop hours to days.
risk - acute glomerulonephritis or eclampsia.
Vomiting, visual disturbances, focal neurologic deficits, and focal or generalized seizures can occur.
BP - 250/150
papilledema, retinal hemorrhages,
Stroke and subarachnoid hemorrhage risk
diagnosis resolution after lowering blood pressure
SLE
autoimmune
young women
skin rash, arthritis, serositis, nephritis, anemia, leukopenia, and thrombocytopenia.
neurologic involvement in 37% to 75%
most common autoimmune cause of encephalopathy.
Laboratory - antinuclear antibodies, anti-native DNA antibodies, anti-Sm antibodies, and false-positive serologic test for syphilis.
Cerebral lupus is treated with corticosteroids,
Seizures are treated with anticonvulsants.
Neurologic symptoms improve in 80%
may also resolve without treatment.
HYPONATREMIA
causes, symptoms, neurologic signs and treatment
brain swelling
Causes - hypothyroidism, adrenal insufficiency, drugs (eg, thiazide diuretics, nonsteriodal anti-inflammatory drugs, ecstasy), SIADH.
symptoms - headache, lethargy, confusion, weakness, muscle cramps, nausea, and vomiting.
Neurologic signs - confusional state or coma, papilledema, tremor, asterixis, rigidity, extensor plantar responses, focal or generalized seizures, and occasionally focal neurologic deficits.
Neurologic complications - Na less than 120
Treatment - underlying cause
Immediate management - water restriction, hypertonic saline with or without intravenous furosemide.
Vitamin B6 deficiency
classic clinical syndrome is a seborrhoeic dermatitis-like eruption, atrophic glossitis with ulceration, angular cheilitis, conjunctivitis, intertrigo, and neurologic symptoms of somnolence, confusion, and neuropathy
פגיעות בדליריום
ערנות, גירוי, אוריאנטציה, התמצאות, קשב
HYPONATREMIA -
Excessively rapid correction complications
central pontine myelinolysis (osmotic demyelination syndrome ),
confusional state, paraparesis or quad-riparesis, dysarthria, dysphagia, hyper- or hyporeflexia, and extensor plantar responses.
Severe cases - locked-in syndrome and coma
MRI may show pontine and extrapontine white matter lesions.
no treatment for central pontine myelinolysis, so prevention is essential
rasie serumn NA at rate not exceeding 8 mmol/L/d.
MCA
vessels anatomy - function
Vessels:
Ascending - rolandi - broca, precentral, postcentral
Descending - parietal, temporal, optic radiation, visual cortex, WERNIKE
Leticulostriate - basal nucli
MCA ischemia
Clinical findings by vessel
Rolandi, ascending- hemiparesis contra lateral without leg!!!
Hemihipoesthesis contra lateral
Motor aphasia (broca)
Descending- contralateral hemonymus hemianopsia (temporal)
Wernike - sensory aphasia
Parietal - neglect (non dominant lobe), agraphia…
Lenticulostriate - total hemianopsia
Aphasia
Hemihipoesthesis
ACA ischemia
Clinical findings
Blood supply to frontal lobe and precentral gyrous of leg
Contralateral monoparesis of leg
Urine incontinance
Cognition - disinhibition, apathy (upper part)
Behave ( lower part)
בדיקת מעבדה הכי ספציפית לאנצפלופטיה כבדית
גלוטמין נמוך - CSF
