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Surat Tanprawate, MD, MSc(London), FRCP(T) Division of Neurology, Chiang Mai University
COMA
and ACUTE CONFUSIONAL STATE
Practical approach
History taking
as the patient can not talk, then ask their relative or witness
Physical examination
evaluate location and cause evaluate severity
GCS
CPOMR
Conscious: drowsy, stupor, semi-coma, coma Pupil: dilate, constrict, response to light, uni-bilateral abnormality Ocular movement: dolls eye, eye deviation, nystagmus, ocular bobbbing Respiratory pattern:
The pupil
Parasympathetic control
Sympathetic control
Pupillary pattern
Decerebrate rigiditybilateral upper and lower limb extensor posture, usually the consequence of bilateral mid-brain lesions
Where is it?
COMA
Localizing sign-no Meningeal sign-yes
Severe meningitis
or
CT with CM in bacterial meningitis
Case exercise
A woman with sudden coma complain vertigo, and then sudden coma C=coma, P=pupil 1.5 mm, O=multidirectional nystagmus, and ocular bobbing, M=quadriplegia, R=apneustic breathing
GCS=E1VTM1
Cause of delirium - intracranial cause: stroke, cerebritis, etc. - extracranial cause: elyte imbalance, deoxygenation etc. - multiple medical/surgical condition
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Sensory aphasia
Acute stroke
when the patient has sudden neurological deficit; symptoms depend on where is the brain is involved
cerebellar sign
cortical sign alter mental state
TOAST classification
Large-artery atherosclerosis(emboli/thrombosis)
Cardioembolism(high-risk/mediumrisk)
Small-vessel occlusion(lacune)
Stroke of other determine etiology Stroke of undetermined etiology
CT brain, non-contrast
Hemorrhagic stroke
sensitivity
100% Minor or subtle signs : loss of lentiform nucleus, loss of insular ribbon, loss of gray-white differentiation and sulcal effacement
Ischemic stroke
Early decompressive surgery for malignant MCA infarction : NNT =2 for death prevent
3-4.5
5 Min
25 Min
Brain herniation
Subfalcine (A) Uncal (B) Central (C) Extradural (D) Tonsillar (E)
Herniation syndrome
Treatment IICP
20-30 (Jugular vein)
osmotherapy: Mannitol* 0.25-0.5 g/kg 20 46 10% Glycerol 250 ml 30-60 4 50% Glycerol 50 ml 4 / Furosemide 1 mg/Kg
Treatment IICP
hypotonic solution
Hyperventilation Pco2 30-35 mmHg steroid
Acute processes
Drug Toxicity
Hypoxia
Status Epilepticus
SE > 10 minutes
(Treiman 1980)
Complication of SE
Acidosis Cerebral edema Hypoglycemia Other: arrhythmia, hyperthermia,
hyperkalemia, DIC, rhabdomyolysis, myoglobinuria, renal failure
Management of SE
Clarify: is it seizure?? If seizure is not stop; consider AEDs Complete general, and neuro-exam Brain imaging if indicate
Key
treat early as possible step up AED is depended on stage of
SE
Pre-monitory status(0-5 min) Early status(5-30 min) Established status(30-60 min) Refractory status(>60 min)
Drug used
diazepam, phenytoin(Dilantin), valproic
acid(Depakine), levetirazetam(Keppra)
Topiramate(feed)
AED treatment
Diazepam (i.v. bolus)
Diazepam (i.v. bolus) followed by phenytoin (iv load) or sodium valproate (i.v. loading) or levetiracetam (i.v.)
half dose i.v. load of previous drug, if seizure dont stop, load another drug
Propofol (i.v.), or midazolam (i.v.), or thiopental (i.v.) or phenobarbital (i.v.) or topiramate (feed)
Diazepam
diazepam 10 mg (2-5mg/min) max 10 mg per dose can be repeated 2 doses
Phenytoin
Vial: 250 mg/5 ml/vial
Dilantin 1000 mg+0.9%NSS 100 cc iv drip in 20 min. then Dilantin 100 mg+0.9%NSS 100 cc iv drip in 15 min
Valproic acid
Vial: 400 mg/4 ml/vial
starting dose: 20-30 mg/kg (rate < 50 mg/min) maintenance: 1-2 mg/kg/hr (max 60 mg/kg/day) e.g. weight 50 kg
Depakine 1000 mg+0.9%NSS 100 cc iv drip in 30 min. then Depakine 100 mg/hr (10 cc/hr)
warning: hepatotoxicity
Midazolam
starting dose: 0.1-0.3 mg/kg bolus (rate < 4 mg/min) maintenance: 0.05-0.4 mg/kg/hr e.g. weight 50 kg
Levetiracetam (Keppra)
Vial: 500 mg/5 ml 0.9% NaCl or 5% Dextrose/w 100 ml starting dose: 2,000-4,000 mg/kg in 15 min maintenance: 10-30 mg/12 hr e.g. weight 50 kg
Propofol
Vial: 10 mg/ml
5% Dextrose/w
Consult is required
Thiopentone
Vial: 1 g/vial
Consult is required
Phenobarbital
5% Dextose
Topiramate for SE
Clinical trial: 500 mg every 12 hours
noso/orogastric feed for 2 days then 150 mg-750 mg every 12 hours
Monitoring
Tapering off AED seizure stop > 24 hours Burst suppression on EEG > 24
hours
Seizure 1. Seizure or not seizure: history, neuro exam 2. Identify cause, ABCD management 3.Start AEDs if seizure tend to be recurrent 4. if seizure is going to be status; need to be quick, and follow up the status epilepticus guideline therapy