Altered Conscious Level Flashcards
what are the causes of altered conscious level?
- Collapse secondary to cardiovascular disease
- Hypoxaemia and/or hypercarbia due to respiratory failure
- Shock due to any cause (sepsis, hypovolaemia, anaphylaxis)
- Diabetic emergency (DKA, hyperosmolar hyperglycaemic state, hypoglycaemia)
- Endocrine emergencies
- Hypothermia
- Hepatic encephalopathy
- Uraemic encephalopathy
- Poisoning and overdose
- Seizures and epilepsy including eclampsia
- Head injury
- Acute stroke
- Cerebral tumour or infection
- Intracranial bleeds
- Alcohol or substance misuse
- Mental health conditions
AVPU
alert?
patient is aware of examiner and can respond to environment on their own, they can follow commands, open eyes spontaneously and track objects
AVPU
verbally responsive?
patients eyes don’t open spontaneously but do in response to verbal stimulus. They are able to react to verbal stimulus directly and in a meaningful way
AVPU
painfully responsive?
eyes don’t open spontaneously, only respond to application of painful stimuli by an examiner. They may move, moan, cry out
AVPU
unresponsive?
doesn’t respond spontaneously, they don’t respond to verbal or painful stimuli
how does AVPU scale correlate to GCS?
- GCS 15 = alert
- GCS 12-13 = verbally responsive
- GCS 5-6 = physically responsive
- GCS 3 = unresponsive
what are the features of the glasgow coma scale?
eye response (4) verbal response (5) motor response (6)
what are the common causes of blackouts?
- Syncope with or without seizures
- Panic attacks
- Epilepsy
- Blank spells/microsleeps
- NEAD (non epileptic attack disorder)
- Narcolepsy
- Hyperekplexia
- Idiopathic drop attacks
- Migraine without headache
- TIA
- POTS
what is syncope?
Loss of consciousness usually from a sudden decrease in cerebral blood flow, majority of patients seen in ‘first seizure’ clinics. Syncope often followed by ‘syncopal/hypoxic’ seizure
what are the types of syncope?
reflex (vasovagal) orthostatic carotid sinus syncope reflex anoxic attacks cardiac respiratory CNS
describe reflex (vasovagal) syncope?
Most common in young
Exaggeration of normal cardiovascular response
Triggers and clinical features
• Prolonged standing, rising, emotional trauma, pain, venepuncture, sign of blood
•Gradual onset, light headedness, nausea, sweating, palpitations, greying of vision, muffled hearing, feeling distant
• Pallor, cold skin, uncoordinated jerks, rapid recovery with no confusion
describe orthostatic syncope?
- Common in older age
- Medications – postural hypotension
- Autonomic neuropathy (MD, alcohol, amyloid)
- Autonomic failure (MSA, PD)
- Features: change in posture, rising, after meals
describe carotid sinus syncope?
- Hypersensitivity of carotid sinus
* Attributable to neck pressure (tight collar, neck turning)
describe reflex anoxic attacks?
- Children
* Increased vagal tone with brief asystole
when does cardiac syncope occur?
- Can occur with no prodrome
- In any posture
- Can occur when awake or asleep, at rest and during activity
what are the causes of cardiac syncope?
Structural heart disease • Aortic stenosis • Hypertrophic obstructive cardiomyopathy • Mitral stenosis • Atrial myxoma • Ischaemic heart disease
Bradyarrythmias
• Complete heart block
• Sick sinus syndrome
• Swallow syndrome – in glossopharyngeal neuralgia
Tachyarryhmia
• Wolf Parkinson white
• Long ganong levine
• Long QT syndrome – congenital, acquired
describe respiratory syncope?
- Cough synope – lead to bradyarrythmia
- Valsalva manoeuvre – lead to bradyarrythmia
- Breath holding spells – common in children / adults with anxiety
- Hyperventilation – drop in CO2 -vasoconstriction
describe CNS syncope?
Rare Raised intracranial pressure • 3rd ventricle colloid cyst • Chiari malformation • Obstructive hydrocephalus Autonomic dysreflexia • Intermittent massive hypertension Diencephalic attacks • Post head injury or hypoxia • Hypertension, sweating, tachycardia, loss of consciousness
what are the behavioural differential diagnosis of seizures/blackouts?
- Hyperventilation
* Psychogenic non epileptic attacks
what are the cerebrovascular disorder differential diagnosis of seizures/blackouts?
- TIAs
- Migraine
- Transient global amnesia - Transient memory loss, Hours, Repeated questions, rare, stress, occurs once
what are the movement disorder differential diagnosis of seizures/blackouts?
- Dystonia
- Myoclonic jerks
- Startle disorders
- Tremor disorders
- Choreoathetosis/ballismus
what are the sleep disorder differential diagnosis of seizures/blackouts?
- Narcolepsy – sleep in inappropriate situatons
- Cataplexy – REM sleep intrusion into wakefulness
- Sleep apnoea – common, under recognised
- Parasomnias – occur in first few hours of sleep
- Periodic limb movements of sleep
- REM behaviour disorder (dissociation of REM sleep and atonia) – act out dream
- Night terrors- children
what are the toxic, metabolic, infectious differential diagnosis of seizures/blackouts?
- Hypoglycaemia
- Recreational drugs
- Phaeochromocytoma
- Carcinoid syndrome
- Porphyria
- Hyper-ammonaemia
- Ketosis
- Lactic acidosis
- Organic acidosis
differential diagnosis of seizures/blackouts
vertigo?
- BPPV – common, positional
- Menieres disease (progessive deafness)
- Vertebrobasilar insufficiency (rare, over diagnosed)
describe non epileptic attack disorder?
- Usually dissociative phenomenon and not malingering
- Some sufferers have epilepsy as well
- Occur in people with learning difficulties as often as rest of population
- Sufferers often have other ‘unexplained’ medical symptom conditions
- Common to have history of abuse and complex psycho/social problems
- Can sustain significant injuries during attacks
- Usually occur in company
- Patient often reluctant to discuss symptoms
- Attacks are variable and not stereo typed
- Might verbalise during attacks and show some awareness, may respond to communication, patient is ‘suggestible’
- Normal pupil size
- Movements are flailing, arched back, pelvic thrusting
- Eyelids are clenched with resistance to eye opening
- Rapid recovery.
describe typical signs/symptoms of a patient with cerebrovascular syncope?
reaches maximum deficit in seconds without altered awareness unless massive stroke
describe typical signs/symptoms of onset in a patient with syncope due to seizures?
deficit may evolve over a few minutes
describe typical signs/symptoms of onset in a patient with syncope due to migraine?
deficit evolves over minutes to an hour with or without headache, should not cause altered awareness. May start as visual aura getting worse, followed by other facial sensory symptoms which can involve arm, legs and progress dysphasia etc this deficit happens graduallt in stroke it would be sudden
what kind of symptoms are seen in a patient with syncope due to migraine compared to ischaemia?
- Migraine causes positive visual symptoms
* Ischaemia causes negative visual symptoms
describe postural orthostatic tachycardia syndrome POTS?
- Uncommon but real entity
- Diagnosis often missed – thought to be psychogenic
- Characterised by orthostatic tachycardia
- Measure heart rate supine, then standing – immediately after 1 min and then after 3 mins
- Does not cause drop in BP
- Can cause loss of consciousness
SEIZURE 1. trigger 2. prodrome 3. onset 4. duration 5. convulsive jerks 6. incontinence 7. lateral tongue bite 8. colour 9. postictal recovery 10 postictal confusion 11. seziure at night from sleep
- rare (flashing, hyperventilation)
- common (aura, dejavu)
- may be sudden
- 1-2 mins
- common (prolonged)
- common
- common
- pale (partial seizure), red/blue
- slow (confused)
- common
- common
SYNCOPE 1. trigger 2. prodrome 3. onset 4. duration 5. convulsive jerks 6. incontinence 7. lateral tongue bite 8. colour 9. postictal recovery 10 postictal confusion 11. seziure at night from sleep
- common (upright, bathroom, blood, needle, exertion)
- almost always (nausea, sweating, palpitation, light headed, visual greying)
- gradual (mins)
- 1-30 secs
- common (brief)
- common
- rare
- very pale
- rapid
- rare
- rare (unless cardiac)
DISSOCIATIVE SEIZURE
- incontinence
- post ictal confusion
- ictal crying
- asynchronous arm and leg movement
- recurrent status
- common
- rare
- occasional
- common
- common
DISSOCIATIVE SEIZURE
- multiple unexplained symptoms
- multiple surgical procedures and investigations
- on treatment for psychiatric condition
- history of abuse
- situational (anger frustration)
all common
DISSOCIATIVE SEIZURE
- induced by suggestion
- onset
- duration
- retained consciousness
- pelvic thrusting, back arching
- common
- gradual
- prolonged
- common
- common
DISSOCIATIVE SEIZURE
- fighting, need to be held, may injure others
- eyes closed
- resisting eye opening
- occurs only in company
- tongue bite/injury
- common
- common
- common
- common
- rare
EPILEPTIC SEIZURE
- incontinence
- post ictal confusion
- ictal crying
- asynchronous arm and leg movement
- recurrent status
- common
- common
- very rare
- rare
- rare
EPILEPTIC SEIZURE
- multiple unexplained symptoms
- multiple surgical procedures and investigations
- on treatment for psychiatric condition
- history of abuse
- situational (anger frustration)
all rare
EPILEPTIC SEIZURE
- induced by suggestion
- onset
- duration
- retained consciousness
- pelvic thrusting, back arching
- less common
- sudden
- seconds - minutes
- rare
- rare
EPILEPTIC SEIZURE
- fighting, need to be held, may injure others
- eyes closed
- resisting eye opening
- occurs only in company
- tongue bite/injury
- rare
- rare
- rare
- rare
- common
- what is epilepsy?
2. what is seizure?
- a disorder characterised by a tendency to recurrent seizures
- represents an episode which occurs when there is a sudden, excessive, disordered discharge of cerebral neurones
describe the tradditional classification of epileptic seizures?
- Focal (partial) vs generalised (at onset) – with descriptive or anatomical localisation
- Simple vs complex (complex = alteration in awareness)
- Idiopathic vs symptomatic
what is the role of the frontal lobe?
- Intellectual function
- Praxis
- Inhibition
- Bladder continence
- Saccadic eye movement (eye deviate away from area of brain)
- Motor function (extension of limb, spread of movement from arm to limb)
- Expression of language
what is the role of the temporal lobe?
- Memory
- Smell
- Hearing
- Vestibular
- Emotion
what is the role of the occipital lobe?
vision
what is the role of the parietal lobe?
- Sensory integration
* Receptive language
what are the types of generalised seizure under the old classification?
- Atonic
- Tonic – stiffness of limbs
- Clonic -jerking
- Tonic clonic
- Myoclonic – sudden twitchy jerk of body
- Absence
what are the 3 levels in the 2017 classification of epilepsy and seizures?
- define seizure type
- Define epilepsy type
- Define syndromic diagnosis
what are the types of seizure?
- Focal or generalised or unknown at onset
- Simple or complex
- Does seizure remain focal or does It evolve into a bilateral seizure (previously refered to as focal seizure with secondary generalisation)
describe a seizure of focal onset?
- motor: automatisms, hyperkinetic, myoclonic, atonic, clonic, tonic
- Non motor onset: autonomic, behaviour arrest, cognitive, emotional, sensory
describe a seizure of generalised onset?
- Motor: tonic clonic, clonic, tonic, myoclonic, atonic, epileptic spasms
- Non motor: typical, atypical, myoclonic, eyelid myoclonia
describe a seizure of unknown onset?
- Motor: tonic clonic, epileptic spasms
* Non motor: behaviour arrest
what are the types of idiopathic generalised epilepsy?
- Childhood absence epilepsy
- Juvenile absence epilepsy
- Juvenile myoclonic epilepsy
- Generalised tonic clonic epilepsy
- Genetic generalised epilepsy
name some epilepsy syndromes?
- West syndrome
- Dravet syndrome
- Lennox gastaut
- Unvericht-lundborg syndrome
- Self limiting syndromes eg benign Rolandic epilepsy
what are the likely causes of epilepsy with an age of onset 0-2 years?
birth trauma
congenital defects
familial epileptic syndrome/channelopathy
what are the likely causes of epilepsy with an age of onset 2-12 years?
idiopathic generalised epilepsy, trauma, infections, accidental poisoning
what are the likely causes of epilepsy with an age of onset 12-30 years?
trauma, alcohol and toxins
what are the likely causes of epilepsy with an age of onset over 50 years?
trauma, alcohol and toxins, tumours, CVAs
what are the likely causes of epilepsy with an age of onset over 70 years?
trauma, alcohol and toxins, tumours, CVAs, dementia