Impaired Consciousness

1
Impaired Consciousness

• Dr Nin Bajaj
• Consultant Neurologist
• QMC DRI

2
Assessment

• Glasgow Coma Scale
• Eye opening-(E)
• Spontaneous-4
• To speech-3
• To pain-2
• None-1

3
GCS

• Best Motor Response- (M)
• Obeys-6
• Localises-5
• Withdraws-4
• Abnoraml flexion-3
• Abnormal extension-2
• None-1

4
GCS

• Verbal Response(V)
• Orientated-5
• Confused conversation-4
• Inappropriate words-4
• Incomprehensible sounds-3
• None-1

5
History

• Acute
• Subacute
• Chronic

6
Acute- quick recovery

• Syncope- vasovagal, cough, micturition, carotid
  hypersensitivity, circulating volume
• Apnoea- hyperventilation, sleep
• Cardiac- arrythmia

7
Acute impairment- no previous hx

• Usually implies a vascular event
• Hemispheric bleed or thrombo-embolic stroke
• Subarachnoid haemorrhage
• Brain-stem event
• Bleed into a tumour?

8
Acute impairment- previous hx

• Might be post-ictal

9
Subacute impairment

• Hours-Days
• Implies systemic or CSF process
• Possibly raised ICP

10
Subacute-systemic

• Electrolyte imbalance- uraemia, hyperammonaemia,
  hypo/hypernatraemic
• Endocrine- hypothyroid, Addisonian
• Infection with reduced cognitive reserve

11
Subacute- CSF process

• Meningitis/Encephalitis
• Neoplastic
• Inflammatory- ADEM, MS, Vasculitic, Sarcoid

12
Subacute- raised ICP

• Usually a rapidly growing tumour
• Consider cerebral venous thrombosis
• Might end up coning

13
Chronic

• Neurodegenerative- Lewy Body, Prion, AD
• Chronic Vascular
• Drug induced- e.g. Anti-cholinergics,
  dopaminergic agents
• Sleep attacks e.g. narcolepsy, synuclein
  deposition

14
Is it a stroke?

• Hemispheric- should be localising neurology
• Bleeds tend to be worse than embolic
• Big MCA infarcts worse
• Can be raised ICP complicating picture

15
Is it a stroke?

• Needs urgent CT brain
• Outside UK, might thrombolyse
• For big MCA, consider skull vault removal or
  dexamathasone/mannitol/over-breathing

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Thrombolysis for Stroke- Inclusion Criteria

• Ischaemic stroke
• Measurable deficit on NIH stroke scale
• No evidence of intracranial bleed on CT brain
• 180 minutes or less from time of symptom onset to
  intiation of IV rt-PA
• IV rt-PA 0.9 mg/kg, 10 as bolus, 90 as infusion
  over 60 min

17
Have they had a SAH?

• Sudden onset
• Worse headache ever, like someone hitting me
  over the head
• Often nausea, vomiting, diplopia, neck stiffness,
  photophobia
• Time to peak pain seconds-minutes
• Pain can last hours, less often days

18
Have they had a SAH?

• Not to be confused with thunderclap headache or
  sex-associated headache
• Sentinel bleed can occur
• Need Urgent CT brain (remains abnormal for up to
  6-10 days)
• If negative, need LP after 12 hours and before 2
  weeks (range 12-33 days) for xanthochromia

19
Have they had a SAH?

• If confirms dx, need nimodipine 60 mg/4hr PO, and
  fluids (gt3l)
• Consider urgent or elective clipping or
  neuroradiological coiling following formal
  angiography
• Endovascular approaches generally best unless
  wide-necked aneursym

20
Have they had a fit?

• Classification
• Generalised or partial
• Grand mal or Petit mal (3Hz spike wave)
• Simple partial or Complex

21
Have they had a fit?

• Markers
• Short, minutes only
• Tongue biting, urinary incontinence, sterotyped
  movements
• GTCS or CPS localising features
• Drowsy and confused afterwards

22
Causes

• Usually primary- ?related to cellular migration
  defects or channelopathy
• Secondary causes include SOL, drugs, stroke,
  alcohol

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Management

• ABC
• First fit- conservative, CT brain, refer to a
  neurologist
• Known epileptic- review drug management

24
Established Epilepsy- Drugs

• Epilim for GTCS but not females
• Lamotrigine GTCS in females
• Tegretol for CPS or Lamotrigine if female
• Phenytoin- status only

25
Status Epilepticus

• Definition
• generalised convulsive status epilepticus in
  adults and older children (gt5) refers to more
  than 5 minutes (USED to be 30 min) of (a)
  continuous seizures or (b) two or more discrete
  seizures between which there is incomplete
  recovery of consciousness

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Status Epilepticus

• Continuing seizure activity for gt30 min
• Diazepam 10-20 mg
• Lorazepam 4 mg IV
• ABC
• Phenytoin, 15-18 mg/kg as IV over 20-30 min,
  cardiac monitor
• Transfer to ITU, phenobarbitone and propofol, CFM

27
Syncope and Seizure

• Postural only?
• Feel hot, clammy- cold sweat
• Vision dark around edges
• LOC seconds only
• No tb, ui, drowsiness, confusion
• ?arrythmia, pale as a sheet
• micturition, cough, emotional trigger
• Hyperventilation, migraine
• Carotid sinus- e.g. stiff collar

28
Investigating Syncope

• ECG- look for WPW, long QT syndromes
• If abnormal, 24hr ECG or loop monitor
• Postural BP
• Tilt table with CSM

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Management

• Emotional or specific trigger- avoid stimulus
• Neurogenic with positive tilt table- salt and
  fluids, orthostatic training, fludrocortisone,
  midodrine
• Cardiac- pacemaker