Approach to
Patients with
Reduced alertness
Dr Subhankar Chatterjee
Associate In-Charge of CCU
Calcutta Heart Clinic & Hospital
Continuum of states of alertness
1.
2.
3.
4.
Conscious Alert and cooperative
Drowsy
Reduced alertness with easy arousal
Stupor
Can be awakes by vigorous stimuli
Coma patient cannot be aroused
Please use specific terms when describing a patient
Anatomy of consciousness
The ascending RAS, from the lower
border of the pons to the ventromedial
thalamus
The cells of origin of this system occupy a
paramedian area in the brainstem
Physiology of consciousness
Cerebral neurons are fully dependant on
blood supply(CBF) and delivery of oxygen and
glucose.
CBF~55ml per 100gm/min
Oxygen consumption~3.5mL per 100gm/min
Glucose utilization is 5mg per100gm/min
Brain store of Glucose provide energy for
2min after blood flow is interrupted
Oxygen store last for 8-10 second after blood
flow cessation
Principle causes of coma
1. Cerebral mass lesions
Principle causes of coma
2. Metabolic disorders
A. Interrupting delivery of energy substrate
Hypoxia
Hypoglycemia
Ischemia
B. Altering neuronal excitability
Drug overdose or unknown toxin
Alcohol intoxication
Anaesthesia
Epilepsy
C. Change in Ion Flux or neurotransmitter abnormality
Hyponatremia
Hypercalcemia
Change in osmolality
Hypercapnia
Hyperammonia
Metabolic causes of coma
D. Increased permeability of BBB to toxic substances
Uremia
E. Others
Hypothyroidism
Vit B12 deficiency
Hypothermia
In all metabolic disorders degree
of neurologic deficit co-relate
with Rapidity
Causes of coma cont..
5. Coma due to widespread
4. Toxic coma
( including
drug induced)
Very commonusually reversible
damage of cerebral
hemisphere
Hypoxic
encephalopathy
Cerebral malaria
TTP
Hyperviscocity
Diffuse axonal injury
following head trauma
Usually irreversible
Approaches to DD
Unresponsive
ABCs
Glucose, ABG, Lytes, Mg,
Ca, Tox, ammonia
IV D50, naloxone,
flumazenil
Brainstem N
or other
Focal signs
Y
CT
N
Unconscious
Pseudo-Coma
Psychogenic,
Looked-in,
NM
paralysis
Diffuse brain dysfunction
metabolic/ infectious
Focal lesions
Tumor, ICH/SAH/ infarction
LP
CT
Glasgow Coma Scale
Monitoring level of consciousness (score 3-15)
Eyes open
1.
Never
2.
To pain
3.
To verbal stimuli
4.
spontaneously
Best verbal response
1.
No response
2.
Incomprehensible sounds
3.
Inappropriate words
4.
Disoriented and converses
5.
Oriented and converses
Best motor response
1.
No response
2.
Extension (decerebrate rigidity)
3.
Abnormal flexion (decorticate rigidity)
4.
Flexion-withdrawal to pain
5.
Localizes pain
6.
Obeys commands
Immediate investigations
Blood Sugar
ABG
LFTs
Urea and Creatinine
Blood and urine cultures
CBC
Other investigations
CRP
Toxic screen , drug levels
Lumbar puncture
CXR
CT scan
History
Onset- sudden/gradual
Pre existing diseaseAssociated complain
Examination
Broad category of D/D
coma
With focal neurodeficit
Management
depends on the
cause
Case 1
70 yrs old male, known
hypertensive
presented in
emergency with
sudden onset LOC.
O/E- pulse 130/min,
BP-230/130, pupilconjugate deviation to
left, right hemiplegia,
E2M4V2
Next??
Manage ABCs
Is there any focal sign??
CT scan brain
Treatment:
ABC
Mannitol 1gm/kg loading
Urgent neurosurgical consultation
Case 2
75 yr/female presented in drowsy state,
relatives say she had repeated bouts of
vomiting in last 2 days.
O/E= pulse 110/min, temp-98,BP120/80, resp20/min, chest, NAD, no
rash
Next what to ask from history?
Next??
On asking family says she is diabetic,
took 30 unit Insulin daily but no food
yesterday.
So, What is the provisional diagnosis?
CBG 35mg%
Case3
78yr/male known hypertensive stays
single in a flat was discovered
comatose by his servant. He says,
patient was very lethargic since 2
days, even could not visit the family
doctor.
O/E= Vitals- stable, no neck rigidity,
no lateralising neurodeficit, no rash.
Next?
Case 3
CBG 130mg%, CT brain
Next??
TLC-12000, Na-120meq/L
Relatives found that patient took tab
Lasix 40mg BD for hypertension.
Case4
25yr female presented to ED in
unconscious state. She had a hot talk
with her husband few min ago before
she had LOC. She had locked jaw,
shivering of whole body.
Next ??
O/E- vitals- stable, No neurodeficit
CBG-100mg%,,
Na-135meq/L
EEG- normal
Ct Brain- NAD
Case 5
70/lady presented with gradually
increasing drowsiness over 1 week. No
h/o diuretic use, non diabetic
O/E-vitals stable, No focal neurodeficit,
no meningism, fundus- normal
Next??
CBG 130mg%
CT brainEEG- slow wave
Na- 135meq/L
TSH- 2.1
TLC-6700
CRP-4.0
Next??
On asking for drug history family says
she never took sedative, no diuretic but
he was on Vit D3 Injection for
Osteoporosis.
Serum Ca-14.0
Case 6
65/male presented with progressive
drowsiness with fluctuating symptom,
often he becomes aggressive.
Vitals- stable, No focal deficit, no
meningism.
Investigation- TLC-10,000, Na129meq/L, Ca-9.0, TSH-2.5, CBG135mg%,
Psychiatrist called.
NEXT ?
Case 7
70/female presented in a drowsy state.
She had a past h/o CVA 6 months back,
bed bound since the attack,
catheterized.
O/E- pulse-110/min, BP-110/70, Chestclear, No new neurodeficit, no
meningism, dehydrated.
No sedative drug, No Vit inj.
Next ??
CBG-120mg%
Na-143meq/L
Ca-8.4meq/L
CT brain
TSH-4.5
Next ??
Urine RE- pus cell plenty,
Patient was started IV antibiotic, Iv
fluid.
Urine C/S- E Coli
Case 8
20 yr/male, had RTA and presented
with LOC.
O/E- pulse-50/min, BP 160/100, lefthemiplegia, E2M3V2, temp 98
Next??
CT Brain Acute SDH
patient underwent urgent
neurosurgery
After 10 days following surgery
Patient had a vacant look, persistent
left weakness, afebrile.
CBG 120mg, Na-135meq/L, Ca-9.0,
CT brain- no blood clot
No sign of sepsis
Diffuse axonal injury
Case 9
75/male smoker presented with SOB 3
days, with acute onset drowsiness 6
hrs.
Pulse 120/min, BP-160/90, Chest- B/L
decreased air entry, No focal
neurodeficit, No meningism
Next ??
CBG 130mg
Na-135
CT brain- normal
Septic profile -normal
Next ??
Next ??
ABG- pH-7.20
Pco2- 100
PaO2-105
Hco3-30
Case 10
35yrs old diabetic lady
attended marriage
ceremony of a relative 3
days ago. Then she had
repeated vomiting,
presented in drowsy
state.
O/E- pulse120/min,
BP100/60, chest clear,
No meningism, no focal
deficit, grossly
dehydrated.
Next ??
CBG- Hi
Na-149meq/L
ABG- 7.30/38/70/18
Urine ketone ++
Case 11
65/male, known hypertensive, stopped
amlodipine 1 week back for no reason,
presented with acute onset drowsiness
for 6 hrs.
Pulse100/min, BP200/100,
papiledema+, No focal neurodeficit, No
meningism
Next ??
CBG 120mg%
Na- 135meq/L
Ca-8.5
TSH 2.3
MRI brain- No stroke/ hemorrhage
Next ??
BP was controlled gradually with Iv
Labetolol, amlodipine
Patient improved within 24 hrs
Case 12
65/female was brought from 60km
distance local hospital for drowsiness.
She was hypertensive, diabetic. Her
son says that she was rescued breaking
the door.
O/E- E2M5V2, pupil- Normal, No focal
deficit, No meningism,
BP 150/90, no papilledema
Next ??
CBG-150mg%
Ca-7
Na-130
CT brain-normal
What history may suggest the
diagnosis??
Next ??
Sedative overdose this patient after
48 hrs became awake and gave history
that she took 20 alprax tab after a hot
talk with her son.
Case 13
24/male presented with fever of 2
weeks followed by drowsiness. He had
2 episodes of convulsion at home.
O/E- pulse 130/min, BP-100/70, neck
rigitity+, pupil- mid dilated, no focal
deficit.
Next ??
CBG-120
Na-136
Ca-9
Next ??
CT brain
CSFcell count 1000( Neutrophil40%,
lymphocyte 55%)
sugar 80mg%
Tubercular meningitis
Case 14
70 yr lady, known hypertensive
presented with sudden LOC.
O/e- GTCS, E2M5V2, Left hemiparesis
BP-220/120,pulse 120, Irregular
CT Brain- on admission
Next?
CT was apparently normal, Patient was
managed with IV Mannitol, Phenytoin,
ET tube for securing airway.
CT repeated after 3 days
CT after 3 days:
Cardio-embolic stroke
Are you drowsy?
