? ?O???O??S ????st?? st?? ??T

1
? ?O???O??S ????st?? st?? ??T ??????s? -
?a?a???????s?
?eµes?? 2008
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???S???

• F?s????????
• ?a?a????µa Delirium????a Dementia
• F?t??? ?at?stas?
• ?at?stas? locked-in
• ??µa
• ???efa????? ???at??

4
??t?a
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??a???st??? p??sp??as?
6
Te?ape?a
7
??????s?
8
???efa???? ?e?t?????a

• Te??e?ta? f?s???????? ?ta? ??e? ?? p?? ??t?
  d?ad??as?e? e??a? a??pafe?
• S??e?d?t?p??e? t?? p??s?p??? t?? ?pa??? ?a? t??
  pe??ß?????ta ????.
• ???at?t?ta ?a a?t??aµß??eta? s?st? ta e??te????
  e?e??sµata a?s??t??? e?e??sµata ?a?
  p??sa?at???sµ??
• ???at?t?ta ?a ap????e?e? ?a? ?a a?a?a?e?
  p????f???e? µ??µ?
• ???at?t?ta epe?e??as?a? t?? a??t??? ded?µ???? µe
  ap?t??esµa t?? pa?a???? ??????? s?µpe?asµ?t??
  d??at?t?ta ???s??, d??at?t?ta ???s?µ?p???s?? t??
  d?ad??as?a? a?t??-a?t?at?

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???efa???? ?e?t?????a

• ??ata?a??? ?p?p?d?? S??e?d?s??
• ??s??s?-S??e?d?t?t?ta t?? p??s?p???? ?pa???? ?a?
  t?? pe??ß?????t?? ????????????s?
• ??ata?a??? t?? ?e??e??µ???? t?? S??e?d?s??
  ???t???? ??ata?a???
• ???at?t?ta ?a a?t??aµß??eta? s?st? ta e??te????
  e?e??sµata a?s??t??? e?e??sµata ?a?
  p??sa?at???sµ??
• ???at?t?ta ?a ap????e?e? ?a? ?a a?a?a?e?
  p????f???e? µ??µ?
• ???at?t?ta epe?e??as?a? t?? a??t??? ded?µ???? µe
  ap?t??esµa t?? pa?a???? ??????? s?µpe?asµ?t??
  d??at?t?ta ???s??, d??at?t?ta ???s?µ?p???s?? t??
  d?ad??as?a? a?t??-a?t?at?
• ...

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S??????S?

• ? s??e?d?s? af??? t?? a?s??s?-s??e?d?t?t?ta t??
  p??s?p???? ?pa???? ?a? t?? pe??ß?????t?? ?????
• ??e? d?? s?stat??? a?????pe??e??µe?a st???e?a
• ???at?t?ta af?p??s?? ?p?ped? s??e?d?s?? µe t??
  ?????a t?? e??????s??
• ?p????s? / ???s? ? d??at?t?ta a?a?????s??/e?µ??e?
  a? /?ata??af?? t?? e?e??sµ?t?? ?a? a?tap????s??

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S??????S?

• ? s??e?d?s? af??? t?? a?s??s?-s??e?d?t?t?ta t??
  p??s?p???? ?pa???? ?a? t?? pe??ß?????t?? ?????
• ??e? d?? s?stat??? a?????pe??e??µe?a st???e?a
• ???at?t?ta af?p??s?? ?p?ped? s??e?d?s??
• ?p????s? / ???s? ? d??at?t?ta a?a?????s??/e?µ??e?
  a? /?ata??af?? t?? e?e??sµ?t?? ?a? a?tap????s??

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???S???

• F?s????????
• ?a?a????µa Delirium????a Dementia
• F?t??? ?at?stas?
• ?at?stas? locked-in
• ??µa
• ???efa????? ???at??

15
???S??? / ?p?peda pa????????? ep?p?d?? s??e?d?s??
??????????
F?t??? ?at?stas?
???p?p???µ??? ap? PL Marino
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Clinical Levels of Altered Consciousness
Terms Eyes Arousability Content
Lethargy Closed Arousable Mildly impaired
Stupor Closed Arousable with effort Markedly impaired
Coma Closed Unarousable Not applicable
Akinetic mutisma (abulic state, coma vigil) Open Wakeful Impaired
Locked-in syndromeb Open Wakeful Normal
aSecondary to bilateral frontal/basal forebrain dysfunction. b Secondary to basis pontis dysfunction. aSecondary to bilateral frontal/basal forebrain dysfunction. b Secondary to basis pontis dysfunction. aSecondary to bilateral frontal/basal forebrain dysfunction. b Secondary to basis pontis dysfunction. aSecondary to bilateral frontal/basal forebrain dysfunction. b Secondary to basis pontis dysfunction.
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??µa

• S???????, a?ast????µ? ? ??? a?ep???e?a t??
  e??efa????? ?e?t?????a?, ?p?? ? as?e??? de? ??p??
  ?a? de? a?t??aµß??eta? pa?? ta e??te???? ??t??a
  e?e??sµata.
• S???st? µ?a ape???t??? ??a t?? ??? epe????sa
  ?at?stas? p?? ??e???eta? s?st?µat??? p??s????s?
  ?a? a?t?µet?p?s?

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??t?a ??µat??

• ??p???? d?µ???? ß??ße? t?? e??ef????
• Fa????ta? se ?.?. ???ef???? ?ta? e??????ta?
• ?????te? aµf?te??p?e??e? ß??ße? sta e??efa????
  ?µ?sfa???a ? ?µ?sfa?????? ß??ße? p?? p???a????
  p????? ?/?a? d?as????d?a?? e????easµ? ß??ße?
  st? st??e???
• ?e?t???????? ß??ße?
• ???ße? µe a???t??? ?.?. ???ef????
• F?s????????
• ?? p?????sa ta d?? ???t???a

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??t?a ??µat?? ??µ???? ß??ße?
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??t?a ??µat?? ??µ???? ß??ße?

• Symetrical, structural
• Supratentorial
• Bilateral internal carotid occlusion
• Bilateral anterior cerebral artery occlusion
• Sagital sinus thrombosis
• Subarachnoid hemorrhage
• Thalamic hemorrhage
• Trauma-contusion, concussion
• Hydrocephalus

Relatively common asymmetrical presentation
UpToDate 15.3
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??t?a ??µat?? ??µ???? ß??ße?

• Symetrical, structural
• Infratentorial
• Basilar occlusion
• Midline brainstem tumor
• Pontine hemorrhage
• Central pontine myelinolysis

Relatively common asymmetrical presentation
UpToDate 15.3
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??t?a ??µat?? ??µ???? ß??ße?

• Asymetrical, structural
• Supratentorial I
• Thrombotic thrombocytopenic purpura
• Disseminated intravascular coagulation
• Nonbacterial thrombotic endocarditis (marantic
  endocarditis)
• Subacute bacterial endocarditis
• Fat emboli
• Unilateral hemispheric mass (tumor, abscess,
  bleed) with herniation
• Subdural hemorrhage bilateral
• Intracerebral bleed
• Pituitary apoplexy
• Massive or bilateral supratentorial infarction

Relatively symmetrical presentation UpToDate
15.3
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??t?a ??µat?? ??µ???? ß??ße?

• Asymetrical, structural
• Supratentorial II
• Multifocal leukoencephalopathy
• Creutzfeldt-Jakob disease
• Adrenal leukodystrophy
• Cerebral vasculitis
• Cerebral abscess
• Subdural empyema
• Thrombophlebitis
• Multiple sclerosis
• Leukoencephalopathy associated with chemotherapy
• Acute disseminated encephalomyelitis

Relatively symmetrical presentation Up-To-Date
15.3
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??t?a ??µat?? ??µ???? ß??ße?

• Asymetrical, structural
• Infratentorial
• Brainstem infarction
• Brainstem hemorrhage
• Brainstem thrombencephalitis

Up-To-Date 15.3
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??t?a ??µat?? ?e?t???????? ß??ße?
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??t?a ??µat?? ?e?t???????? ß??ße?

• Symetrical, nonstructural
• Infections
• Bacterial meningitis
• Viral encephalitis
• Postinfectious encephalomyelitis
• Syphilis
• Sepsis
• Typhoid fever
• Malaria
• Waterhouse-Friderichsen syndrome

Up-To-Date 15.3
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??t?a ??µat?? ?e?t???????? ß??ße?

• Symetrical, nonstructural
• Metabolic I
• Hypoxia
• Hypercapnia
• Hypernatremia
• Hypoglycemia
• Hypergylcemic nonketotic coma
• Diabetic ketoacidosis
• Lactic acidosis
• Hypercalcemia
• Hypocalcemia
• Hypermagnesemia

Relatively common asymmetrical presentation
UpToDate 15.3
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??t?a ??µat?? ?e?t???????? ß??ße?

• Symetrical, nonstructural
• Metabolic II
• Hyperthermia
• Hypothermia
• Reye's encephalopathy
• Aminoacidemia
• Wernicke's encephalopathy
• Porphyria
• Hepatic encephalopathy
• Uremia
• Dialysis encephalopathy
• Addisonian crisis
• Hypothyroidism

Relatively common asymmetrical presentation
UpToDate 15.3
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??t?a ??µat?? ?e?t???????? ß??ße?

• Symetrical, nonstructural
• Drugs

Sedatives Salicylate
Barbiturates Psychotropics
Other hypnotics Anticholinergics
Tranquilizers Amphetamines
Bromides Lithium
Alcohol Phencylidine
Opiates Monoamine oxidase inhibitors
Paraldehyde
Relatively common asymmetrical presentation
UpToDate 15.3
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??t?a ??µat?? ?e?t???????? ß??ße?

• Symetrical, nonstructural
• Toxins
• Lead
• Thallium
• Mushrooms
• Cyanide
• Methanol
• Ethylene glycol
• Carbon monoxide

Up-To-Date 15.3
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??t?a ??µat?? ?e?t???????? ß??ße?

• Symetrical, nonstructural
• Psychiatric
• Catatonia
• Other
• Postictal seizure
• Diffuse ischemia (myocardial infarction,
  congestive heart failure, arrhythmia)
• Hypotension
• Fat embolism
• Hypertensive encephalopathy
• Hypothyroidism
• Nonconvulsive status epileptics
• Heat stroke

Relatively common asymmetrical presentation
UpToDate 15.3
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??t?a pa????????? ep?p?d?? s??e?d?s??
Trauma
?p? PL Marino
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?? ? as?e??? p???e? ???t???a??µat?d??? ?
p????µat?d??? ?at?stas?? ??e???eta? epe????sa
a???????s? ?a? ?e?ape?a p?? ?????ta?
ta?t?????a?a? ?e?????? st? ????
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????????s?
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????????s? ?

• ?st?????
• G??st?? ??s??, f??µa?a, ?at????s? a?????, ??s???
• ?????f???e? ap? t??? ???e???? / d?as?ste?
• Medicalert
• ?a??t?ta e?s?d??
• ?p???a, ?s?a?µ?a, ?p?????a?µ?a, Spasµ??, SAH,
  ?s?a?µ??? ??? Ste??????
• ?p??at??a?µ?a, ?pe??at??a?µ?a, ?pe?????a?µ?a,
  ?????? ?p?s?????d??, ????? e??ef????
• ?p?t??p?????te? spasµ??, ?p?s?????d?? a?µ?t?µa,
  µetaß????? a?t?a
• ?????????ta s?µpt?µata ?a? s?µe?a

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????????s? ??

• Vital signs and general examination
• Neurologic examination and GCS

UpToDate 15.3
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S?µe?a

• S?µa?t??? ?p??tas?
• ?p?tas?
• ?pe??e?µ?a
• ?p??e?µ?a
• ??p?? a?ap????

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S?µe?a
?pe?ae??sµ?? ?pe?ae??sµ?? ?pe?ae??sµ??
Metabolic acidosis pH lt7.3, PaCO2 lt30 mmHg, HCO3 lt17 mmol/L Uremia, diabetic ketoacidosis, lactic acidosis, salicylates, methanol, ethylene glycol
Respiratory alkalosis pH gt7.45, PaCO2 lt30 mmHg, HCO3 gt17 mmol/L Hepatic failure, acute sepsis, acute salicylate intoxication, cardiopulmonary states with hypoxemia, psychogenic causes
Up-To-Date 15.3
44
S?µe?a
?p?ae??sµ?? ?p?ae??sµ?? ?p?ae??sµ??
Respiratory acidosis pH lt7.35 (if acute), PaCO2 gt90 mmHg, HCO3 gt17 mmol/L Respiratory failure from central (eg, brain or spinal cord) or peripheral nervous system disease, chest conditions or deformities. Coma only with severe hypercarbia.
Metabolic alkalosis pHgt 7.45, PaCO2 gt45 mmHg, HCO3 gt30 mmol/L Vomiting, alkali ingestion. Usually no impairment of consciousness if so, suspect psychogenic unresponsiveness or additional cause.
Up-To-Date 15.3
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S?µe?a
Antecubital needle marks Opiate drug abuse
Pale skin Anemia or hemorrhage
Sallow, puffy appearance Hypopituitarism
Hypermelanosis (increased pigment) Porphyria, Addison's disease, chronic nutritional deficiency, disseminated malignant melanoma, chemotherapy
Icterus Hepatic dysfunction or hemolytic anemia
Petechiae Disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, drugs
Petechial-purpuric rash Meningococcemia, other bacterial sepsis (rarely), gonococcemia, staphylococcemia, pseudomonas, subacute bacterial endocarditis, allergic vasculitis, purpura fulminans, typhus, fat emboli
Up-To-Date 15.3
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S?µe?a
Cherry-red skin Carbon monoxide poisoning
Generalized cyanosis Hypoxemia or carbon dioxide poisoning
Grayish-blue cyanosis Methemoglobin (anailine or nitrobenzene) intoxication
Localized cyanosis Arterial emboli or vasculitis
Telangiectasia Chronic alcoholism, occasionally vascular malformations of the brain
Vesicular rash Herpes simplex, varicella, Bechet's disease, or drugs
Ecchymosis Trauma, corticosteroid use, abnormal coagulation from liver disease or anticoagulants
Up-To-Date 15.3
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51
S?µe?a
Macular-papular rash Typhus, candida, cryptococcus, toxoplasmosis, subacute bacterial endocarditis, staphylococcal toxic shock, typhoid, leptospirosis, pseudomona sepsis, immunological disorders (systemic lupus erythematosus, dermatomyositis, serum sickness)
Ecthyma gangernosum Necrotic eschar often seen in the angenital or axillary area in Pseudomonas sepsis
Gangerene of digits' extermities Emboli to larger peripheral or arteries
Splinter hemorrhages Linear hemorrhages under the nail, seen in subacute bacterial endocarditis, anemia, leukemia, and sepsis
Osler's nodes Purplish or erythematous painful, tender nodules on palms and soles, seen in subacute bacterial endocarditis
Pigmented macules Tuberous sclerosis, neurofibromatosis
Up-To-Date 15.3
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53
S?µe?a
Macular-papular rash Typhus, candida, cryptococcus, toxoplasmosis, subacute bacterial endocarditis, staphylococcal toxic shock, typhoid, leptospirosis, pseudomona sepsis, immunological disorders (systemic lupus erythematosus, dermatomyositis, serum sickness)
Ecthyma gangernosum Necrotic eschar often seen in the angenital or axillary area in Pseudomonas sepsis
Gangerene of digits' extermities Emboli to larger peripheral or arteries
Splinter hemorrhages Linear hemorrhages under the nail, seen in subacute bacterial endocarditis, anemia, leukemia, and sepsis
Osler's nodes Purplish or erythematous painful, tender nodules on palms and soles, seen in subacute bacterial endocarditis
Pigmented macules Tuberous sclerosis, neurofibromatosis
Up-To-Date 15.3
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55
S?µe?a
Macular-papular rash Typhus, candida, cryptococcus, toxoplasmosis, subacute bacterial endocarditis, staphylococcal toxic shock, typhoid, leptospirosis, pseudomona sepsis, immunological disorders (systemic lupus erythematosus, dermatomyositis, serum sickness)
Ecthyma gangernosum Necrotic eschar often seen in the angenital or axillary area in Pseudomonas sepsis
Gangerene of digits' extermities Emboli to larger peripheral or arteries
Splinter hemorrhages Linear hemorrhages under the nail, seen in subacute bacterial endocarditis, anemia, leukemia, and sepsis
Osler's nodes Purplish or erythematous painful, tender nodules on palms and soles, seen in subacute bacterial endocarditis
Pigmented macules Tuberous sclerosis, neurofibromatosis
Up-To-Date 15.3
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57
S?µe?a
Macular-papular rash Typhus, candida, cryptococcus, toxoplasmosis, subacute bacterial endocarditis, staphylococcal toxic shock, typhoid, leptospirosis, pseudomona sepsis, immunological disorders (systemic lupus erythematosus, dermatomyositis, serum sickness)
Ecthyma gangernosum Necrotic eschar often seen in the angenital or axillary area in Pseudomonas sepsis
Gangerene of digits' extermities Emboli to larger peripheral or arteries
Splinter hemorrhages Linear hemorrhages under the nail, seen in subacute bacterial endocarditis, anemia, leukemia, and sepsis
Osler's nodes Purplish or erythematous painful, tender nodules on palms and soles, seen in subacute bacterial endocarditis
Pigmented macules Tuberous sclerosis, neurofibromatosis
Up-To-Date 15.3
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60
S?µe?a
Macular-papular rash Typhus, candida, cryptococcus, toxoplasmosis, subacute bacterial endocarditis, staphylococcal toxic shock, typhoid, leptospirosis, pseudomona sepsis, immunological disorders (systemic lupus erythematosus, dermatomyositis, serum sickness)
Ecthyma gangernosum Necrotic eschar often seen in the angenital or axillary area in Pseudomonas sepsis
Gangerene of digits' extermities Emboli to larger peripheral or arteries
Splinter hemorrhages Linear hemorrhages under the nail, seen in subacute bacterial endocarditis, anemia, leukemia, and sepsis
Osler's nodes Purplish or erythematous painful, tender nodules on palms and soles, seen in subacute bacterial endocarditis
Pigmented macules Tuberous sclerosis, neurofibromatosis
Up-To-Date 15.3
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63
S?µe?a
Battle's sign, raccoon eyes trauma
Acetone, alcohol breath Ketoacidosis alcohol intoxication
Fever Infection
Tongue laceration Incontinence Postictal state
64
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65
?e????????? e??tas?

• ???a? s??t?µ? ?a? af???
• ?p?ped? s??e?d?s??
• ???e?
• ????se?? ?f?a?µ??
• ??p?? a?ap????
• ????t??? a?tap????s?
• ? a?e??es? est?a??? ?e?????????? s?µe??? ?d??e?
  se p??t??e?? ?e????????? ??s?

66
?e????????? e??tas?

• ???a? s??t?µ? ?a? af???
• ?p?ped? s??e?d?s??
• ???e?
• ????se?? ?f?a?µ??
• ??p?? a?ap????
• ????t??? a?tap????s?
• ? a?e??es? est?a??? ?e?????????? s?µe??? ?d??e?
  se p??t??e?? ?e????????? ??s?

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Eye opening Eye opening
Spontaneous 4
Response to verbal command 3
Response to pain 2
No eye opening 1
Best verbal response Best verbal response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No verbal response 1
Best motor response Best motor response
Obeys commands 6
Localizing response to pain 5
Withdrawal response to pain 4
Flexion to pain 3
Extension to pain 2
No motor response 1
Glasgow coma scale
68
Up-To-Date 15.3
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?e????????? e??tas?

• ???a? s??t?µ? ?a? af???
• ?p?ped? s??e?d?s??
• ???e?
• ????se?? ?f?a?µ??
• ??p?? a?ap????
• ????t??? a?tap????s?
• ? a?e??es? est?a??? ?e?????????? s?µe??? ?d??e?
  se p??t??e?? ?e????????? ??s?

70
?e????????? e??tas?

• ???a? s??t?µ? ?a? af???
• ?p?ped? s??e?d?s??
• ???e?
• ????se?? ?f?a?µ??
• ??p?? a?ap????
• ????t??? a?tap????s?
• ? a?e??es? est?a??? ?e?????????? s?µe??? ?d??e?
  se p??t??e?? ?e????????? ??s?

71
Up-To-Date 15.3
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?e????????? e??tas?

• ???a? s??t?µ? ?a? af???
• ?p?ped? s??e?d?s??
• ???e?
• ????se?? ?f?a?µ??
• ??p?? a?ap????
• ????t??? a?tap????s?
• ? a?e??es? est?a??? ?e?????????? s?µe??? ?d??e?
  se p??t??e?? ?e????????? ??s?

73
(No Transcript)
74
?e????????? e??tas?

• ???a? s??t?µ? ?a? af???
• ?p?ped? s??e?d?s??
• ???e?
• ????se?? ?f?a?µ??
• ??p?? a?ap????
• ????t??? a?tap????s?
• ? a?e??es? est?a??? ?e?????????? s?µe??? ?d??e?
  se p??t??e?? ?e????????? ??s?

75
?e????????? e??tas?

• ???a? s??t?µ? ?a? af???
• ?p?ped? s??e?d?s??
• ???e?
• ????se?? ?f?a?µ??
• ??p?? a?ap????
• ????t??? a?tap????s?
• ? a?e??es? est?a??? ?e?????????? s?µe??? ?d??e?
  se p??t??e?? ?e????????? ??s?. ?a?at????µe t??
  a?t?µat? ??s?, t?? t???, t?? a?t?µate? ????se??,
  t?? a?t?d?as? sta ep?d??a ?a? ta e? t? ß??e?
  a?ta?a??ast???

76
Up-To-Date 15.3
Aminoff MJ, Greenberg DA, Simon RP Clinical
Neurology, 3rd ed. Norwalk, CT, Appleton Lange,
1996
77
????????s? I

• History
• Vital signs and general examination
• Neurologic examination and GCS
• Screening laboratories (CBC, glucose
  selectrolyes, BUN, creatinine, PT, PTT, ABG,
  LFTs, drug screen)
• ECG

UpToDate 15.3
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????????s? ??

• Head CT scan prioritize emergent if focal
  neurologic signs, papilledema, fever
• Lumbar puncture prioritize emergent after CT
  scan if fever, elevated WBC, meningismus
  otherwise do according to level of suspicion for
  diagnosis or if cause remains obscure

UpToDate 15.3
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????????s? ???

• EEG for possible nonconvulsive seizure, or if
  diagnosis remains obscure
• Other laboratory tests blood cultures, adrenal
  and thyroid tests, coagulation tests,
  carboxyhemoglobin, specific drug concentrations -
  do according to level of suspicion for diagnosis
  or if cause remains obscure
• Brain MRI with DWI, if cause remains obscure

UpToDate 15.3
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83
Te?ape?a ?

• ABCs
• Intubate if GCS 8
• Stabilize Cspine
• Supplement O2
• IV access
• Blood pressure support as needed

UpToDate 15.3
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Te?ape?a ??

• Glucose 25g (after blood drawn, before results
  back)
• Thiamine 100mg IV
• Treat definite seizures with diazepam, phenytoin
  or equivalent
• Consider empiric treatments

UpToDate 15.3
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Te?ape?a ???

• Consider empiric treatments
• For possible infection
• Ceftriaxone, Ampicillin and Vancomycin
• Acyclovir
• As early as possible
• For possible ingestion
• Naloxone 0.4-2.0 mg
• Flumazenil
• Gastric lavage/activated charcoal

UpToDate 15.3
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Te?ape?a ?V

• Consider empiric treatments
• For possible increased ICP
• Mannitol
• For possible nonconvulsive status
• Lorazepam / Diazepam
• Phenytoin or equivalent
• For possible ADEM after measles
• High dose methylprednizolone or Immunoglobulin
• For myxedema coma
• IV T4 200-300µg?100µg, T3, hydrocortizone

UpToDate 15.3
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Te?ape?a V

• After cardiac arrest
• Therapeutic hypothermia NNT 6
• Body temperature lt 38o C
• MAP 80-100 mmHg at least for the first 24h
• Normocapnia
• Glucose and seizure control
• Exclude nonconvulsive SE if there is no clinical
  improvement
• ICP monitoring if clinical signs of herniation or
  CT scan findings of cerebral edema

Geocadin RG et al Crit Care Clin 22 (2007)
619636
88
???G?OS?

• ??a????? a?t???
• As therapies aimed at cerebral resuscitation and
  preservation following acute injury are developed
  and proved efficacious, prior guidelines for
  determining prognosis will require redefinition
  and reconfirmation Axel J. Rosengart, Roberta
  L. Novakovic, Jeffrey I. Frankin Principles of
  Critical Care 3rd Ed Part IV Neurologic
  Disorders 2007
• ???????? ????µµata
• ?at???? ?p??d?s? st?? ?e?t?st?p???s? t??
  pa?e??µe??? ?p??es??? ??e?a? ?ste t??????st?? ?a
  d?asfa???eta? ?t? ? p?????s? e?t?µ?ta? af??
  p??sf?????e t? d??at? µ???st?.

89
S??????S???? ?

• ??µa e??a? ? ?at?stas? p?? ? as?e??? de? ??p??
  ?a? de? a?t??aµß??eta?
• ?p?te?e? epe????sa ?at?stas? ?? p??? t?? a?????
  d?asf???s?? t?? ae?a????? ?a? d??t? ??p??a
  ?p??e?µe?a a?t?a e??a? ape???t??? ??a t?? ??? ?a?
  ta?t?????a p????? ? e? µ??e? a?ast????µa.

• ?e???a?at?µ??? t? ??µa ?fe??eta? se d????t?
  e??efa???? d?s?e?t?????a ? se p??t??e?? ß??ß? t??
  ste?????? ? de?te???e?? s?µp?es? t?? ste??????
• S?????? t? ??µa ?fe??eta? se µetaß????? a?t?a ?
  d???t???as? ap? f??µa?a ?a? se t?a?µa

90
S??????S???? ??

• ? a???????s? t?? as?e?? a??????e? µ?a se??? ?a?
  ta?t?????a ?????e?ta? ? a????? ?e?ape?a.
• ?? s?µa?t???te?? ??????? s?µe?? p?? d?a?????e? t?
  µetaß?????-t????? ??µa ap? t?? p??t?pa?? ß??ß?
  t?? e??ef???? e??a? ?a a?t?d???? ?? ???e? st? f??.

• ? ?e????????? e??tas? t?? ??µat?d??? as?e????
  e??a? s??t?µ? ?a? est???e?
• ?p?ped? s??e?d?s??
• ???e? ?f?a?µ??
• ????se?? ?f?a?µ??
• ??p?? a?ap????
• ????t??? a?tap????s?
• ? ?.?. ???ef???? ap?te?e? t?? p?? a???p?st?
  e??tas? ??a ?a ap???e?st??? d?µ???? ß??ße? t??
  e??ef???? sa? a?t?a t?? ??µat??

91
S??????S???? ???

• ? ?s?a?µ???/a?????? e??efa??p??e?a µet? ap?
  a?a??p? ? ep?µ??? ?atap????a µp??e? ?a ße?t???e?
  µe ep??et??? ?e???p??stas?a p?? st????eta? st??
  a???s? t?? e??efa????? a?µat???? ???? µet? t??
  a?a???????s?
• S?µas?a t?? ?e?ape?t???? ?p??e?µ?a? µet? ap?
  a?a??p?

92
(No Transcript)
93
(No Transcript)
94

• ??O??S??S
• S?????

95
???a??st? p?? µe a???sate
96
(No Transcript)