ACUTE ORGANIC BRAIN SYNDROME:
Are abnormal mental status that begins abruptly , run a course ranging from a few days to 3—4 weeks.
It is associated with intrinsic brain disease with central dysfunction secondary to extra—cerebral physical disease and intoxication.
THE SYNDROMS:
Delirium---- acute brain syndrome Acute confusional state Exogenous psychosis Toxic psychosis Metabolic encephalopathy
Dysmnesic syndrome-----Amnestic syndrome
Wernicke—korsakow syndrome
Quasin functional syndromes
Organic affective syndrome Organic delusional syndrome Organic hallucinosis
DELIRIUM
Most frequent and important syndrome
C/F:
Principal feature---reduction in level of conscious awareness((clouding)).
It is manifested clinically as disorientation in time/space, worse at night.
Other psychological symptoms:
Poorly sustained attention Memory impairment Liability of mood Disordered thought and speech Paranoid misinterpretion Visual and auditory hallucination
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Physical symptoms:
Restlessness , Tremor ,Ataxia ,Slurred speech ,Incontinance.
Behavior disturbance – wandering ,aggressive outbursts
Predisposing factors:
Age—any age- common in young children and elderly pts( dementia).
Environments – sensory and social isolation.
Drugs and alcohol abuse – predispose to delirium more readily
Pathophysiology:
The cerebral dysfunction lie in brain stem reticular formation , thalamic nuclei mainly mid line. This leads to disturbance in arousal ,attention ,wake sleep cycle.
Diagnosis:
EEG--- slowing of alpharhythm (( 8—13)) cycles/ second
Emergence of theta (( 4 ---7 )) cycles /second
Bilateral symmetrical predominant frontal delta waves (( 3)) cycles/s
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CAUSES OF DELIRIUM:
1--Intoxiction—drugs , alcohol ,organic solvents ,glue , fuels, industial toxins ,CO
Poisonous plants and fungi
2--Metabolic – Hypoxia
Hypoglycemia
Electrolyte disturbance
Renal / Hepatic failure
Vit Deficiency (( A/ D))
Endocrine disorders
Porphyria
3--Infections systemic , intracranial
4--Physical injury cranial trauma
Heat stroke
Hypothermia
Radiation
5--Vascular and cardiovascular disorder
Cerebral infarction
HTN encephalopathy
Subarachnoid haemorrhage
Cardiac failure/Arrest/ atrial fibrillation
Collagen vascular disease
6--Intracranial space occupying lesion
Hematoma /Abscess / Tumor
7--Epilepsy
8--Withdrawal syndrome -- Benzodiazepines /Barbiturates /Alcohol/ Chlormethiazole
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MANAGEMENT:
1. Quite room2. Minimum staff changes3. Constant regimen4. Repeated reassurance and explanation of medical procedures.5. Revesible causes to be treated Hypoxia Hypercapnia Vit deficiency Electrolyte disturbance
THE MOST EFFECTIVE TREATMENT IS IDENTIFICATION AND ELEMINATION OF THE CAUSE.
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DRUGS USED IN TREAMENT:
Need of treatment –restlessness
Wandering
Combativness
Behavioral disturbance
Drug therapy-- symptomatic
1.Should be flexible
2.Dosage according to the age and severity of disturbance.
3.Timing ideal with nocturnal variation in behavior
Tranquilizer are effective.
Haloperidol oral I/M I/V
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0.5mg ---10mg /2 - 3 times
Crisis ---5 -10mg I/V highly effective , can be repeated ½ hourly
Phenothiazine---promazine ,chloropromazine,thioridazine
Affective in controlling agitation ,aggression , noisy, restlessness.
Oral or I/M --- 25mg elderly , 500mg young
Benzodiazepines--- diazepam
Effective in alcohol / drug withdrawal delirium
Disadvantage—excessive sedation and increased confusion in elderly
40—80 mg Diazepam daily orally or intravenously.
Chlormethiazole—
Short acting sedation and anticonvalsant with hypnotic properties.
Useful in 1.Alcohlo withdrawal 2. Drug withdrawal
Dose 1—1.5 mg daily orally
1 hour a day of 0.8% I/V
Risk of dependence
Prognosis:
Depends on causative condition
Commonest out come—complete recovery
MR 12%
DRUGS CAUSING DELIRIUM:
Tranqulizer and hypnotics—Barbsiturate,Benzodiazepine,Bromide,Neuroleptics.
CVS drugs---- Digoxin , B blocker , Diuretic
Anticholinergic – Hyoscine, TCA, Antiparkinson,Atropine ,Homatropine
Dopamine agonist—Levodopa, Bromocriptine ,Amantidine
Antituberculosis—INH , Cycloserine , Rifampicine
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Antibiotics---Peniciline ,Streptomycine ,Sulphonamide
Anticonvulsants – Phenytoin , NA valporate
Others –Chloroquine , Hypoglycemic, Piperzine, Disulfiram
Drug withdrawal –Alcohol, Barbiturates ,BZA.
DYSMNESTIC SYNDROME: “ Korsakows syndrome”
C/F:
Characterized by defective retention of memory of new information.
Retention span being less than one minutes with relative sparing of remote memory and intellectual function.
Classically; the memory hiatus is filled by fanfasy memories “ confabulation”
CAUSES:
A.Thiamine deficiency---- alcoholism , hyperemesis gravidarum
B.Wernickes encephalopathy in thiamine deficiency
Alcohol , Vomiting(( upper GIT obstruction , starvation ,anorexia nervosa,hunger shiker)
C/F:
Impairment of consciousness.
Progressing to coma
Ocular and conjugate gaze paralysis
Nystagmus
Truncal ataxia
C.Head injury
D.Encephlitis involving both temporal lobes
PATHOLOGY:
Small puntate haemorrhage in the region of mamary bodies.
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In wernichs ,all the region of III ventricle of brain.
Treatment:
Thiamine 20—100mg daily for a week then contined orally over several wks
Treat the underlaying cause.
QUASIN FUNCTIONAL SYNDROMES:
1.Organic affective syndrome—
Major depression or mania---- drug ingestion // physical illness
2.Organic delusional syndrome—
Schizophrenia // schizo-affection psychosis with delusion , hallucination ,bizarre behavior and though disorders.
3.Organic hallucinosis---
Usually visual in colour
Drugs --- TCA , Antiparkinson , Digoxin ,B blocker ,Pentazocine
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