Disorders of consciousness Flashcards
What is delirium
Acute/sudden confusional state developing within hrs/days (unlike alzheimers) - disturbance of consciousness causing reduced ability to focus or shift attention - fluctuates
Key features of delirium
Evidence of disturbance caused by medical condition, substance intoxication or medication side effect
Sx not explained by pre-existing dementia
Delirium risk factors
Older age
Systemtic Illness (heart attack, stroke, alcohol/drugs, heart failure, renal failure, liver failure, ICU stay, recent surgery/anaesthesia)
INFECTION (UTI, PNEUMONIA, sepsis)
Dehydration
Polypharmacy
Pre-existing dementia
Electrolyte imbalance
metabolic problems (thyroid disorders)
Sleep deprivation
Visual/hearing problems
Symptoms of delirium
Hypoactive or hyperactive
Reduced awareness of environment
Confusion
Drowsy
Distractable
NEW memory impairment (unlike alzheimers)
Hallucinations
Delusions and change in personality/mood
FLUCTUATIONS (unlike dementia)
DDx of delirium
Dementia - progressive
Psychosis
Depression
Stroke
Delirium Ix
The Confusion Assessment Method (CAM) can be used as a scoring system for identifying delirium
Initial
- History, physical exam (low temp could mean cold sepsis) , neurologic exam
- FBC, electrolytes, renal and liver panel
- URINALYSIS and MC&S
- Blood culture
- Toxicology
- Cardiac enzymes / Pro-BNP
- ABG
Scans
- chest X ray (pneumonia, pneumothorax (lack of O2), mass/tumour, heart failure)
- ECG - arryhthmias
- CT/MRI (haemorrhage, encephalitis etc…)
- lumbar puncture (meningitis, subarachnoid haemorrhage)
- EEG
- USS of abdomen and bladder
Delirium management
Treatment of underlying cause
- antibiotcs
- rehydration
- stop meds that may cause
- correct electrolyte, glucose imbalance
sedation if needed - haloperidol or lorazepam
What is meningitis
Meningitis is inflammation of the meninges (PAD - pia mater, arachnoid mater, dura mater)
Usually due to infection (or malignancy/medications) - potentially life threatening condition
Cause of bacterial meningitis
Strep pneumonia esp due to drug resistance to penicillin
N. meningitidis
Common if immunosuppressed e.g. cancer, HIV or if had recent neurosurgery - fatal (high mortality but rare)
Bacterial meningitis symptoms
Fever - rapidly developing
Stiff neck
Headache
Seizures
Photophobia
Altered mental state
Nausea and vomiting
Rash (meningococcemia) or signs of sepsis (non blanching petechial rash)
Bacteria meningitis Ix and findings
Kernig’s sign
Brudzinski’s sign
Blood test and cultures - gives antibiotics immediately after this
Lumbar puncture of CSF - LOW GLUCOSE AND HIGH PROTEIN!!! High WBC = turbid
CT head - mass/tumour
Bacterial meningitis treatment
IV antibiotics twice daily - ceftriaxone or vancomycin
Add ampicillin/amoxicillin in older than 65 due to possible listeria monocytogenes
- give chloramphenicol if allergic to penicillin
IV Steroids (dexamethasone) - to prevent hearing loss (give at same time as antibiotics and continue for 4 days)
Sepsis management
Fluids
BP management with vasoconstrictors
Viral meningitis presentation and findings
Not life threatening and quite common
Cold like symptoms
Typical meningitis symptoms (fever, neck stiffness, vomiting, headache, photophobia, altered consciousness, seizures)
Lumbar puncture - clear, mildy raised/normal protein, normal glucose, high WBC
No bacteria on blood cultures
Viral meningitis management
IV aciclovir
Causes of viral meningitis
Enterovirus
HSV
Vaircella zoster virus (VZV)
Cause of subdural haemorrhage
sudden acceleration - high speed vehicle accident/collision without restraint
falls
assault on head
Presentation of subdural haemorrhage/haematoma
High speed acciden/collision/assault to head
Acute symptoms
Loss of consicousness
Laceration/bruising on head
Nausea and comitting (due to raised intracranial pressure)
Confusion
Alcohol use
RF:
More susceptible if Hx of dementia/alzheimers
Anticoagulant use
Prev history of haemorrhage
Clinical findings of subdural haematoma!!!
CRESCENT SHAPED (SICKLE SHAPED) FEATHERED FLUID OVER SURFACE OFBRAIN OF RADIOLOGICAL SCAN
-causes mass effect and midline shift
- brain lobes unaffected since bleed on outside of brain
Subdural haemorrhage treatment
Intubate to protect airway if loss of consciousness
Refer - neurosurgery
What is epidural haemorrhage
Collection of blood in potential space between dura mater and skull
Causes of epidural haemorrhage
Rupture of middle meningeal artery
Blunt force trauma to temporal/parietal regions!!!
Skull fracture - most common
Differences between subdrual and epidural haemorrhage
Subdural haemorrhage
- venous bleed
- high speed accident main cause
- sickle shaped/crescent shaped on radiology
- outside skull
Epidural haemorrhage
- arterial bleed (gets worse with every pump of heart) - needs treatment ASAP
- blunt force trauma/skull fracture main cause
- may feel ok after initial injury and suddenly deteriorate/lose consciousness later (Lucid interval)
- CSF otorrhea/rhinorrhea
- lens/ballon shaped mass on radiology
- inside skull
Presentation of epidural haemorrhage
Trauma to head
Lucid interval
Loss of consciousness
Elevated intracranial pressure
Neuro deficits
Haemotympanum (blood in ear)
CSF otorrhea, rhinorrhea
Check for use of anticoagulants
Radiological findings for epidural haemorrhage
Lens/ballon shaped mass over surface of brain!!
Mass effect with midline shift
Epidural haemorrhage treatment
Neurosurgery - get blood out
May use drill (burr holes) if no neurosurgery available
Signs of alcohol intoxications
Smell like alcohol
Cerebellar gait
Antisocial, norm violating behaviour
Slurred speech
Urine on clothing
Vomiting
Drowsiness
Signs of alcohol withdrawal
Tremor
Elevated BP/pulse
Seizures
Nausea and vomiting
Anxiety/agitation
Hallucinations
Active alcohol withdrawal and preventing alcohol withdrawal treatment
Benzodiazepines for both preventing and active withdrawal
Thiamine (Vit B1) for chronic alcohols to prevent encephalopathy
Rehydration and alcoholism counselling
Signs of opiate (heroin, methadone) intoxications
Drowsiness, pupullar constriction (pin point pupils), decreased RR, track marks on arms
Opiate intoxication treatment
Naloxone injection
Opiate reversal agent
Substance abuse conselling
