Consciousness disorders, convulsive states Made with OpenOffice.org 1 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). Made with OpenOffice.org 2 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) Made with OpenOffice.org 3 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!! Made with OpenOffice.org 4 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 Made with OpenOffice.org 5 Glasgow coma scale 3 coma 15 points sopor somnolence consciousness Reaction verbal: oriented confused inadequate intelligible no eyes opening: 6 5 4 3 2 1 spontaneous to being addressed to pain does not open eyes motoric: complies with an appeal targeted reaction to pain non-targeted reaction to pain flexion extension no reaction Made with OpenOffice.org 6 Focal neurological symptoms: locomotion disorder perception disorder eye symptoms Made with OpenOffice.org 7 Focal neurological symptoms: eye symptoms anisocoria (different width of pupils) maximum widening = mydriasis = insufficient blood circulation in brain maximum narrowing of pupils = miosis = intoxication with opiates Photoreaction = reaction of pupils to light crossing of eyeballs ( squinting ), spont. movements Made with OpenOffice.org 8 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 Made with OpenOffice.org 9 FA: 1.basic life functions (ABC = foreign bodies, tongue, ...) 1. 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 EMS Made with OpenOffice.org 10 Non-traumatic causes of unconsciousness: Cerebrovascular accidents (CVA) Brain inflammation = infection Diabetic coma ... Collapse, faintness Made with OpenOffice.org 11 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 Made with OpenOffice.org 12 ischemia bleeding Made with OpenOffice.org 13 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 blood pressure, slowed pulse Made with OpenOffice.org 14 FA for CVA: vital functions transport – EMS – treating hospital ABC CT thrombolytics up to 4,5 h from the beginning of sympthoms Face Arms Speach Time Made with OpenOffice.org 15 Made with OpenOffice.org 16 Meningococcus Made with OpenOffice.org 17 Inflammation of brain, meninges Encephalitis, meningitis Causes: bacteria (Neisseria meningitidis = meningococcus) viruses (herpetic virus = herpes) parasites Made with OpenOffice.org 18 Symptoms of meningitis: Made with OpenOffice.org 19 Encephalitis, meningitis – symptoms: fever, breathlessness, meningeal symptoms headache, sickness, vomiting, dizziness head bent backward, stiff neck muscles, flexion of limbs, photophobia, hyperhearing Made with OpenOffice.org 20 FA: ABC temperature regulation, liquids (+paracetamol) – if conscious quiet medical examination (emergency) hospitalisation (blood, CerebralSpinalFluid) Mening. irritation present = high probability of meningitis Made with OpenOffice.org 21 Meningococcal sepsis: Petechia: Do not waste time = call ambulance (high mortality within 24 h in spite of treatment) Penicillin administered in time can save the life. Made with OpenOffice.org 22 Diabetic coma Hypoglycemia Excessive amount of insulin (drugs) Low intake of glucose (vomiting) Alcohol Excessive physical activity LO glucose HI glucose Made with OpenOffice.org Diabetic hyperosmolar syndrome (Relative) low dose of insulin Diabetic ketoacidosis No insulin = no medication Without insulin: Glc can not enter cell Glucose  urine - dehydration cells break down fat – forms toxic acids (ketones). 2 Sings before onset Hypoglycemia Hunger Shakiness or nervousness Anxiety Fatigue Weakness Sweating Nausea Dizziness or lightheadedness Difficulty speaking Confusion, seizures, coma Diabetic hyperosmolar syndrome Diabetic ketoacidosis Increased thirst Frequent urination Fatigue Nausea and vomiting Shortness of breath Stomach pain Fruity breath odor (aceton) A very dry mouth A rapid heartbeat Made with OpenOffice.org 2 Diabetes Mellitus DM type 1: Hypoglycemia Diabetic ketoacidosis If you have either type 1 or type 2 diabetes, the following factors can increase the risk of a diabetic coma: Insulin delivery problems. If you're on an insulin pump, you have to check your blood sugar frequently. One of the reasons for this is that a kink in the insulin pump tubing may stop all insulin delivery without you being aware of it. Even tubeless pumps can sometimes have problems that cause insulin delivery to stop. A lack of insulin can quickly lead to diabetic ketoacidosis if you have type 1 diabetes. An illness, trauma or surgery. When you're sick or injured, blood sugar levels tend to rise, sometimes dramatically. This may cause diabetic ketoacidosis if you have type 1 diabetes and don't increase your insulin dosage to compensate. Other medical conditions, such as congestive heart failure or kidney disease, may increase your risk of diabetic hyperosmolar syndrome. Poorly managed diabetes. If you don't monitor your blood sugar properly or take your medications as directed, you'll have a higher risk of developing long-term complications and a diabetic coma. Skipping insulin. Sometimes, people with diabetes who also have an eating disorder choose not to use their insulin as directed with the hope of losing weight. This is a dangerous, life-threatening practice that increases the risk of a diabetic coma. Drinking alcohol. Alcohol can have unpredictable effects on your blood sugar, sometimes dropping blood sugar levels as late as a day or two after the alcohol was consumed. This can increase your risk of a diabetic coma caused by hypoglycemia. Illegal drug use. Illegal drugs, such as cocaine and Ecstasy, can increase your risk of severe high blood sugar levels, as well as your risk of a diabetic coma. DM type 2: Diabetic hyperosmolary syndrom (middle-aged or older) Made with OpenOffice.org 2 Diabetic coma First Aid Diabetic COMA: If you have no training in diabetes care, care for comatous (= nothink to eat, nothink to drink, DRSABC) and wait for the emergency care team to arrive. If you are familiar with diabetes care, follow these steps: ● Test the unconscious person's blood sugar. – If the blood sugar level is lower than 70 mg/dL (4 mmol/L), administer an injection of glucagon. If glucagon isn't available, rub glucose gel, honey or non-sugar-free syrup on the inside of the unconscious person's cheek. Do not try to give fluids to drink and do not give insulin to someone with low blood sugar. If the blood sugar level is above 4 mmol/l, wait for medical help to arrive. Don't give sugar to someone whose blood sugar isn't low. Let the emergency care team know about the diabetes and what steps you've taken, if any. – https://youtu.be/ybEZmHu7Gds Made with OpenOffice.org 2 Hypoglycemia Alert victim: ● Help to sit or lie down ● Give sugar drink (or glucose gel, help to use it) ● If victim responds quickly = give more food or sugar drink. Advice to see the doctor even if victim feels fully recovered. ● If condition does not emprove = monitor response and activate EMS. Made with OpenOffice.org 2 line up Made with OpenOffice.org 28 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 Made with OpenOffice.org 29 Symptoms of faintness: being pale, sickness, sweating, low blood pressure loss of hearing, vision, loss of consciousness, fall Short-term unconsciousness normal breath, bradycardia, palpable pulse Made with OpenOffice.org 30 FA for faintness: leave lying on the floor, raise legs = autotransfusion 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 – EMS (not a case of faintness) epileptic fit, arrhythmia – doctor Made with OpenOffice.org 31 Convulsive states Made with OpenOffice.org 32 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… + ● Made with OpenOffice.org 33 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 Made with OpenOffice.org 34 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) Made with OpenOffice.org 35 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 EMS: breathing disorders, consciousness disorders, high fever, diabetes, little children, pregnant, first (unknown) occurrence Made with OpenOffice.org 36 Made with OpenOffice.org 37 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 Made with OpenOffice.org 38 Emergence of convulsions in Epilepsy epileptic impulse = photostimulation (cinema, fire), hyperventilation, rhythmical sounds (on a train, music – drums) epileptic focus = cells with pathological electrical activity low spread threshold through the brain Made with OpenOffice.org 39 Epilepsy FA Call EMS: 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. See the neurologist epi. patient with treatment, increased frequecy of fits During fit - care about ABC, ... Made with OpenOffice.org 40 Febrile convulsions Convulsions + consciousness disorder, children (6M .. 6Y) with rapid onset of fever (over 39°C), tachycardia, sweating. FA: cooling: remove blanket, wrap; air the room if conscious – enough liquids, Paracetamol (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 // EMS Made with OpenOffice.org 41 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: EMS, hospitalisation, termination of pregnancy Made with OpenOffice.org 42 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 CO2 Doctor – Calcium i.v. Made with OpenOffice.org 43 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 generalized muscle spasms–> suffocating while fully conscious Prevention: vaccination (re-vaccination á 10y) Prevention: treatment of wound with H 2O2 FA&Th: EMS - artificial respiration Made with OpenOffice.org 44 Botulism Foodborne botulism - ingestion of contaminated food – Clostridium botulinum (home made canned food) – botulotoxin (Wound b., infant b., inhaled) double vision, unclear speaking, difficulties chewing, swallowing muscular weakness, considerable muscular weakness, palsy without convulsions and while fully conscious FA: EMS – UPV, [administration of antitoxin] US: 724 cases of food-borne botulism in 25 y, Made with OpenOffice.org 45 Summary of Neurol. exam: 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 Convulsions ? Time when the person had been without deficit. Made with OpenOffice.org 46