Consciousness disorders, convulsive states Consciousness * Active state of human psyche, expresses relationship between one’s own personality and surrounding world. * Alertness (vigilance), abstraction, verbalization, evaluation, self-consciousness (orientation in time, space, one’s own personality). * Most sensitive indicator of state of human brain (and its blood circulation). Orientation examination of consciousness * spontaneously conscious * reaction to being addressed * reaction to touch * reaction to painful stimulus * no reaction * reaction = opening of eyes; speaking; movement - flexion, extension, shivering * (reaction of pupils to light, position + movement of eyeballs) Changes in quality of consciousness * Changed conscious content (confusedness, stupefied consciousness) * The affected is disoriented; restless | anxious | puzzled. Speaks discontinuously, without succession and meaning, asks repeatedly the same. FA: * !! be calm, do not let the affected get hurt or endanger the surroundings!! Changes in quantity of consciousness * somnolence = as if sleeping, does not speak spontaneously, but is able to wake up by being addressed or touched, fully oriented, but without external stimuli falls asleep again * sopor = does not react to common stimuli, able to be brought to partial consciousness by a short-term strong = painful stimulus (without verbal reaction, only hand movement or blinking) * coma = deep unconsciousness = the affected cannot be woken up by either sound or a painful stimulus, passive position, slowed breathing, sunken tongue, body is lifeless, threat of inhaling content of stomach ... 0 reaction of pupils to light * speed of change in consciousness – the faster the more serious Glasgow coma scale * 3 15 points coma sopor somnolence consciousness Reaction eyes opening: verbal: motoric: 6 complies with an appeal 5 oriented targeted reaction to pain 4 spontaneous confused non-targeted reaction to pain 3 to being addressed inadequate flexion 2 to pain intelligible extension 1 does not open eyes no no reaction Focal neurological symptoms: * locomotion and perception disorder * eye symptoms * anisocoria (different width of pupils) * maximum widening = mydriasis = insufficient blood circulation in brain * maximum narrowing of pupils = miosis = intoxication with opiates * photoreaction disorder = reaction of pupils to light * crossing of eyeballs (squinting), spont. movements Causes of consciousness disorders: * blood circulation disorder (shock) * worsening of brain oxygenation (suffocation, CO intoxication) * brain injury (head injury, cranial fractures) * increase in intracranial pressure (tumour, cerebrovascular accident) * intoxication * disorder of internal environment (hypo-/hyperglycaemia) * infection * epilepsy * injury by electricity FA: 1. basic life functions (ABC = foreign bodies, tongue, ...) 2. if resuscitation is not needed – further examination – look for signs of head, neck, chest, abdomen or limb injuries 3. if spine is not injured – stabilised position and breath and pulse monitoring. 4. nothing per os, look for medicaments, ID for the diabetic, medical report, doctor’s certificate 5. transport by EA Non-traumatic causes of unconsciousness: * Cerebrovascular accidents (CVA) * Brain inflammation = infection ... * Collapse, faintness CVA * Bleeding – from split blood vessel to cerebral tissue – in place of haematoma loss of function sudden loss of function (from 50 years), meningeal symptoms, often high blood pressure * Ischemic – resulting from insufficient blood circulation (blood clots, decrease of blood pressure) typical mild consciousness disorder – only dizziness, nausea function: focal neurological symptoms meningeal stimulation does not occur * Embolism accidents embolus to great blood circulation – head – partial obstruction of arteries * for cardiac rhythm disorders ischemia bleeding CVA symptoms: * Locomotion and perception disorder (face asymmetry, droopy corner) * Eye symptoms * Anisocoria (pupils differently wide) mydriasis, miosis * Photoreaction disorder * Eyeballs shift * Loss of vision * Nausea, vomiting, loss of balance * Increase in pressure, slowed pulse FA for CVA: * vital functions * transport – ambulance – hospital * ABC * CT * thrombolytics up to 3 h from the beginnig Meningococcus Inflammation of brain, meninges Encephalitis, meningitis * Causes: * bacteria (Neisseria meningitidis = meningococcus) * viruses (herpetic virus = herpes) * parasites Symptoms of meningitis: Encephalitis, meningitis – symptoms: * fever, * breathlessness, * meningeal symptoms * headache, * sickness, vomiting, dizziness * head bent backward, stiff neck muscles, flexion of limbs, * photophobia, hyperhearing FA: * ABC * temperature regulation, liquids (+paracetamol)– if conscious * quiet * medical examination (emergency) * hospitalisation Mening. irritation present = high probability of meningitis Meningococcal sepsis: Petechia: Do not waste time = call ambulance (high mortality within 24 h in spite of treatment) Penicillin administered in time can save life. line up Faintness, collapse * Short-term unconsciousness caused by short-term insufficient blood circulation in brain. * Caused by (failure of circulation regulation = hypo-tension) : * exhaustion, heat, long standing, hot space * pain, psyche * sudden change of position – quick standing up Symptoms of faintness: * being pale, sickness, sweating, low blood pressure * loss of hearing, vision, loss of consciousness, fall * Short-term unconsciousness * bradycardia, palpable pulse FA for faintness: * leave lying on the floor, raise legs = auto-transfusion position (better return of blood to heart – recovery of blood circulation in brain = recovery of consciousness) * if recovery of consciousness is fast, colour returns, cause of faintness is known – doctor is not necessary * while unconscious, ABC * if longer than 1 min – ambulance (not a case of faintness) * epileptic fit, arrhythmia – doctor Convulsive states Convulsive states * convulsion = involuntary contraction of striated muscles * occurrence: ● at least 1x in lifetime in as much as 10% of population maximum: ● children 1/2 year to 3-4 years ●… puberty… + Convulsions – classification: * with consciousness disorder: * febrile convulsions in children, epilepsy, eclampsia * without consciousness disorder: * tetanus, tetany * Types of convulsion: * Tonic – overall body stiffness, arched bent of torso, patient stops breathing (cyanosis) = muscle flexes and keeps tense * Clonic – repeated muscle twitches = alternating tension and relaxation Causes of convulsions: * high temperature – febrile convulsions * meningocephalitis, brain inflammation * epilepsy * metabolical changes (Ca^++, hypoglycaemia) * cerebrovascular accidents, intracranial bleeding * tumorous illnesses * poisonings * eclampsia – (formerly EPH gestosis) FA for convulsions: * Prevent secondary injury – fall, injury with surrounding objects * Monitor duration of convulsions, unconsciousness * During and after fit – ABC, stabilised position, limit commotion around = limit stimuli that could cause other convulsions * Ambulance: breathing disorders, consciousness disorders, high fever, diabetes, little children, pregnant, first occurrence * medical treatment: ordinary EPI fit in a known epileptic Emergence of convulsions in Epilepsy * epileptic focus = cells with pathological electrical activity * low spread threshold * epileptic impulse = photostimulation (cinema, fire), hyperventilation, rhythmical sounds (on a train, music – drums) Epilepsy * E. stimulus (rhythmical sound, colours, cinema, television) * Brain reaction: ● sensory symptoms (visual, auditory, olfactory perception) ● fit of convulsions, ● consciousness disorder * Typical GrandMall: Aura, Cry, Fall, Fit Tonic, Clonic, Urine, Sh-- (sleep) * Other manifestations: * Absence = eyes fixed, eyes turned up * Convulsions localised at 1 limb, muscle group Epilepsy FA Call ambulance: * first time in life * diabetes * child * disorder of breathing * Status Epilepticus = A prolonged seizure (usually defined as lasting longer than 30 minutes) or a series of repeated seizures; a continuous state of seizure activity. Not necessary call ambulance * epi. patient – care about ABC, ... Febrile convulsions * Convulsions + consciousness disorder, children (6M .. 6L) with fever (over 39°C), tachycardia, sweating. * FA: cooling: remove blanket, wrap, if conscious – enough liquids, Paralen (painkiller). During a fit of convulsions, unconsciousness (10 min) – * Ensure clear airways. * Do not prevent child from movements during convulsions. * Do not put anything into mouth during convulsions (inhaling). * Medical examination Eclampsia = advanced stadium of EPH gestosis (oedemas, proteinuria, hypertension), illness is related to pregnancy (placenta), * oedema of brain, lungs – disorder of consciousness, convulsions, insufficient breathing, low blood pressure, shock * FA: ambulance, hospitalisation, termination of pregnancy Tetany = increased readiness for convulsions (tonic). * occurs during lower concentration of Ca^++ in blood: changes of internal environment = alkalosis - hyperventilation after psychical stress; (hysteria) - after repeated vomiting * FA: calm patient down, sit in half-upright position [* ]hyperventilation tetany – plastic/paper bag, reinhalation of CO[2] * Doctor – Calcium i.v. Tetanus * infection with Clostridium tetani = spores in soil --> wound --> toxin production (days) – block of neuromuscular transfer: * difficulties chewing, * trismus = flexed chewing muscles, * generalisation of convulsions * paralysis –> suffocating while fully conscious * Prevention: vaccination (re-vaccination á 10y) [* ]Prevention: treatment of wound with H[2]O[2] * FA&Th: artificial respiration Botulinism * ingestion of contaminated food – Clostridium botulinum (home made canned food) – botulotoxin * double vision, unclear speaking, difficulties chewing, swallowing * muscular weakness, considerable muscular weakness, palsy without convulsions and while fully conscious * FA: doctor – UPV, administration of antitoxin Summary: * DR ABC (shake, shout) * what’s your name * where are you * what’s the day today * Do you have some pain? * Can you move? * open, close eyes * whistle * extremities