Altered Consciousness Flashcards by Rai Christiana

Components of Sensorium

• Consciousness
• Attention span
• Orientation to time, place and person
• Fund of information
• Insight, judgement and planning
• Calculation

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Aware that you are aware

Sensorium

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Recognize our awareness of self and environment

Sensorium

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Functions of Sensorium

Proposes various actions and their consequences

• Directs motor system in behaviors for personal survival and satisfaction

• Allows us to experience life as a conscious process with a past, present and future to respond appropriately

Registers current internal and external contingencies

Relates current internal and external stimuli to our memories and to our future hopes and desires

Invests the streams of afferent stimuli with emotion, determines their significance and assigns priority that results in neglect or attention

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Exteroceptors

Eyes ears nose tongue skin

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Proprioceptors

Vestibule muscles tendons

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Interceptors

Thoracicoabdominal viscera

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State of full awareness of self and environment and normal responsiveness to external stimulation and inner needs

Consciousness

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2 elements of consciousness

Arousal (Wakefulness)
Awareness (Content)

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Problems with arousal (wakefulness)

Integrity of ascending reticular activating system (ARAS)

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Problems with awareness (content)

Integrity of cerebral cortex

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Quality and coherence of thought and behavior

Awareness (content)

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Ascending pathway to cerebral cortex

Brainstem reticular formation > ascending projections system > thalamus > diffuse thalamocortical projection > cerebral cortex

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Fully responsive to a thought or perception and indicates by behavior and speech the same awareness of self and environment as that of the examiner

Normal Alertness

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Attention to and interaction with immediate surroundings

Normal Alertness

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Normal alertness may fluctuate during

the day from keen alertness to deep concentration

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Inability to think with customary speed, clarity and coherence

Confusion

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• Impaired judgement and decision making

Confusion

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Confusion

Most often due to a process that affects the whole brain such as

Encephalopathies and dementia

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Test for confusion

• Recall events
• Defect in use of working memory
• Serial subtraction or spelling backwards or digit span and backwards
• Impaired registration

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May incorporate clouded interpretation of internal and external experience, and an inability to integrate and attach symbolic meaning to experience

Apperception

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Degree of confusion varies from hour to hour
• Least pronounced in morning, increases as the day wears on, peaking in early evening hours

Sundowning

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“to go out of the furrow”

Delirium

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Severe inattentiveness, altered mental content and sometimes hyperactivity

Delirium

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Characterized by misperception of sensory stimuli often with hallucinations

Delirium

Delirium disorientation order

Time Place Person

• Inability to sustain a wakeful state without application of external verbal stimuli • Some degree of inattentiveness and mild confusion coupled with drowsiness that improves with arousal • Decreased mental, speech and physical activity • Patient shifts positions naturally and without prompting • Lids droop, may snore, limbs relaxed

Drowsiness

Lt. "to beat against or blunt" • Mental blunting • Mild to moderate reduction in alertness, accompanied by a lesser interest in the environment • Slower response to stimulation • Nonpainful physical stimulation

Obtundation

Lt. "to be stunned" • Deeper state than drowsiness • Patient can be roused only by vigorous and repeated painful stimuli and usually repeated stimulation is required to sustain arousal • Responses to spoken commands are either absent, curtailed or slow and inadequate • Reduction or elimination of natural shifting of positions • Eyes are displaced slightly out and up which is same as in sleep

Stupor

verbal stimulation Or command

Drowsiness

light, physical, nonpainful stimulation

Obtundation

Stupor noxious stimuli

Trapezius squeeze Sternal rub Nail bed pressure Suborbital pressure

Gk. "deep sleep or trance" • Incapable of arousal by external stimuli or inner need • In lighter stage, corneal, pupillary and pharyngeal reflexes can be elicited • In deepest stage, no meaningful or purposeful reaction of any kind is obtainable and corneal, pupillary and pharyngeal responses are diminished

Coma

Patients who, after recovery from coma, return to a state of wakefulness without cognition

Persistent Vegetative State

Eyes-open permanent unconsciousness with loss of cognitive function and awareness of the environment but preservation of sleep-wake cycles and vegetative function

Persistent vegetative state

vegetative syndrome of unconscious awakening persists for - months after nontraumatic brain injury = persistent

vegetative syndrome of unconscious awakening persists for - months after traumatic brain injury = persistent

Causes of persistent vegetative state

Anoxia - Ischemia - worst prognosis • Metabolic or encephalitic coma • Head trauma

MRI of Persistent Vegetative States

global brain atrophy but thalamic and basal ganglia were disproportionately affected atrophy of white matter with secondary ventricular enlargement thinning of corpus callosum • Cortex is diffusely injured or disconnected from thalamus

Automatism

Swallowing Grimacing Grunting Moaning

Motor activity

Primitive postural and reflex movement

Vegetative State Laboratory Test EEG

lack of normal change in background EEG activity during and immediately after stimulating the patient

Neuroimaging of Laboratory test

progressive and profound cerebral atrophy

State of coma in which brain was irreversibly damaged and has ceased to function, but pulmonary and cardiac function could still be maintained by artificial means

Brain Death

State of complete unresponsiveness to all modes of stimulation, arrest of respiration and absence of all EEG activity for 24 hours

Brain Death

person is dead if the brain is dead and that death of brain may precede the cessation of cardiac function

Brain Death

Brain Death features

Absence of all cerebral functions Absence of all brainstem functions inc spongy respiration Irreversible

Absence of cerebral function

• Deep coma • Total lack of spontaneous movement and of motor and vocal responses to all visual, auditory and cutaneous stimulation

Absence of brainstem function

• Loss of pupillary response • Loss of corneal, oculocephalic, oculovestibular (caloric testing), gag and cough reflex • Absence of facial movement to noxious stimuli • Absence of cerebrally mediated movement to noxious stimulation of extremities

Apnea Test is the destruction of

Medulla

Abnormal Apnea Test

Pa CO2 = 60mmHg

Destruction of the medulla

Apnea Test

• Unresponsiveness of medullary centers to high carbon dioxide tension

Apnea Test

Apnea Test Absence of tachycardia in response to

Atrophine

Apnea Test

Damaged Vagal Neurons

Confirms cerebral death • Electrocerebral silence, flat or isoelectric EEG

EEG

- lack of contrast pacification during 4VA

• Digital subtraction angiography (DSA)

used to rule out reversible cause

Toxicology screening

hypothermia or intoxication with sedative-hypnotic drugs and immediately post cardiac arrest

Isoelectric EEG w/ preserved brainstem reflexes

GCS Year

1978

GCS is by

Graham Teasdale and Bryan Jennett

• Scale used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma

Glasgow Coma Scale

3 aspect of GCS

Eye Opening Verbal Response Motor Response

GCS P Year

2018

GCS P by

Paul Brennan Gordon Murray Graham Teasdale

Mild TBI

13-15

Moderate TBI

9-12

Severe TBI

3-8

GCS-P of severe TBI

1-8

Alteration in sensorium

Trauma Infectious Metabolic Nutritional Vascular Neoplastic

Trauma sample

epidural/subdural/subarachnoid/intracerebral

Infectious sample

meningitis, encephalitis, brain abscess

Mass lesion/neoplastic

neoplasm, abscess, hematoma, granuloma, cyst

Vascular sample

cerebral infarction/hemorrhage/SAH

Focal Lesion

mass lesion, infarction, hematomas

Multifocal Lesion

Multiple tumors, mass lesions

Diffuse lesion

Metabolic endocrine, toxic encephalopathy

Causes of alteration in consciousness

Structural Functional

-discrete lesion ex. hematoma -widespread destructive changes of the hemispheres - increased ICP

Structural

metabolic, toxic, nutritional d/t neuronal failure in the cerebrum and RAS

Functional

Destructive lesion immediately within thalamus or midbrain

Direct damage to ARAS

Interruption of thalamocortical impulses or generalized destruction of cortical neurons

Widespread bilateral damage to cortex and cerebral white matter

Disturbance in higher intellectual functions • Seizure • Language problem • Behavioral, personality and mental changes • Contralateral hemiparesis with Babinski • Contralateral hemisensory deficit • Visual field deficit

Cerebrum

•CROSSED MOTOR/SENSORY SYNDROME • Ipsilateral cranial nerve deficit • Contralateral hemiplegia with Babinski • Contralateral hemisensory deficit

Brainstem

Truncal ataxia • Limb ataxia

Cerebellum

Behavioral and personality changes may be the initial presentation • Acute confusional episode • Delirium • Alteration of consciousness • Generalized seizures • FND are usually absent but if present, they are bilateral

Encephalopathy

Causes of alteration in consciousness

Primary brainstem lesion Bihemispheral lesion Secondary brainstem compression Encephalopathy