Impaired Consciousness

Dr Nin Bajaj

Consultant Neurologist

QMC & DRI

Assessment

• Glasgow Coma Scale

• Eye opening-(E)

• Spontaneous-4

• To speech-3

• To pain-2

• None-1

GCS

• Best Motor Response- (M)

• Obeys-6

• Localises-5

• Withdraws-4

• Abnoraml flexion-3

• Abnormal extension-2

• None-1

GCS

• Verbal Response(V)

• Orientated-5

• Confused conversation-4

• Inappropriate words-4

• Incomprehensible sounds-3

• None-1

History

• Acute

• Subacute

• Chronic

Acute- quick recovery

• Syncope- vasovagal, cough, micturition, carotid hypersensitivity, circulating volume

• Apnoea- hyperventilation, sleep

• Cardiac- arrythmia

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?

Acute impairment- previous hx

• Might be post-ictal

Subacute impairment

• Hours-Days

• Implies systemic or CSF process

• Possibly raised ICP

Subacute-systemic

• Electrolyte imbalance- uraemia, hyperammonaemia, hypo/hypernatraemic

• Endocrine- hypothyroid, Addisonian

• Infection + with reduced cognitive reserve

Subacute- CSF process

• Meningitis/Encephalitis

• Neoplastic

• Inflammatory- ADEM, MS, Vasculitic, Sarcoid

Subacute- raised ICP

• Usually a rapidly growing tumour

• Consider cerebral venous thrombosis

• Might end up coning

Chronic

• Neurodegenerative- Lewy Body, Prion, AD

• Chronic Vascular

• Drug induced- e.g. Anti-cholinergics, dopaminergic agents

• Sleep attacks e.g. narcolepsy, synuclein deposition

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

Is it a stroke?

• Needs urgent CT brain

• Outside UK, might thrombolyse

• For big MCA, consider skull vault removal or dexamathasone/mannitol/over-breathing

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

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

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

Have they had a SAH?

• If confirms dx, need nimodipine 60 mg/4hr PO, and fluids (>3l)

• Consider urgent or elective clipping or neuroradiological coiling following formal angiography

• Endovascular approaches generally best unless wide-necked aneursym

Have they had a fit?

• Classification

• Generalised or partial

• Grand mal or Petit mal (3Hz spike & wave)

• Simple partial or Complex

Have they had a fit?

• Markers

• Short, minutes only

• Tongue biting, urinary incontinence, sterotyped movements

• GTCS or CPS localising features

• Drowsy and confused afterwards

Causes

• Usually primary- ?related to cellular migration defects or channelopathy

• Secondary causes include SOL, drugs, stroke, alcohol

Management

• ABC

• First fit- conservative, CT brain, refer to a neurologist

• Known epileptic- review drug management

Established Epilepsy- Drugs

• Epilim for GTCS but not females

• Lamotrigine GTCS in females

• Tegretol for CPS or Lamotrigine if female

• Phenytoin- status only

Status Epilepticus

• Definition:

• “generalised convulsive status epilepticus in adults and older children (>5) 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”

Status Epilepticus

• Continuing seizure activity for >30 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

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

Investigating Syncope

• ECG- look for WPW, long QT syndromes

• If abnormal, 24hr ECG or loop monitor

• Postural BP

• Tilt table with CSM

Management

• Emotional or specific trigger- avoid stimulus

• Neurogenic with positive tilt table- salt and fluids, orthostatic training, fludrocortisone, midodrine

• Cardiac- pacemaker