IMPAIRMENT OF CONSCIOUSNES

S (ACS)

Dr. Boroumand

CONSCIOUSNESS

Cortex:Awareness (HCF)

Brain Stem:Awakeness = ARAS

Posterior Fossa

LEVEL OF CONSCIOUSNESS (AWAKNESS)(MEANS : ARAS)

Full Awake(alert)

Drowsiness

Stupor

Coma

Acute Confusional

States

Or Delirious

State

COMA

Pathologic Sleep

BRAIN STEM AND ARASBrain Stem:

1-Awakeness2-Respiration3-Eye Fixation4-Sleep Cycle5-Weight gain

6-Yaupping7-Cardiac Rhythm

8-Bilateral Long Tract Pathways (Hemi to Tetra paresis)Posterior Fossa

VEGETATIVE STATE

Means : Cortex (off) + Brain Stem

(on)(cortical Death)

Loss of AwarenessDuration > 6 m/o = PVS

LOCKED IN SYNDROME

Localization : Bilateral Ventral Pontine Lesions

Quadriplegia + Lower Cranial Nerve Palsy Causes:

1 -Pontine Stroke

2 -CPM

3 -MS 4 -ALS

5 -Alzhiemer’s Disease

6 -GBS

7 -NMJ-Blockers Drugs

8 -Brain stem lesions (Lymphoma-Glioma- TB- Syphilis)

BRAIN DEATH

Syn.: Irriversible Coma

Cortex off + Brain Stem off + Obvious Lesion + Irriversible Damage

Obvious Lesion Means: Bilateral Cortical Damage or Structural Lesion in BS

In Brain Death: EEG is flat

BRAIN DEATH CRITERIA

: مغزی مرگ کرایتریای باشد کوما در بیمار خودبخودی تنفس وجود عدم مغزی ساقه های رفلکس فقدان در EEGسکوت مغزی خون جریان فقدان مانند مغزی پذیر برگشت علت هرگونه فقدان

فنوباربیتال با مسمومیت

Irriversible Coma = Brain Death

PHENOBARBITAL INTOXICATION

Cortex Off Brain Stem Reflexes off EEG is completely Flat

BUT:

Obvious lesion (-) CT and MRI (NL)

TX IN PHEN. TOXICITY

Forced Alkaline Diuresis

AS A RULE:

↓ in LOC means:

1- Bilateral Cortical Damage

2- Brain stem Structural Damage

3- Unilateral Supratentorial Damage extending toward the brain stem or the other Side

LEVEL OF CONSCIOUSNESS (AWAKNESS)

Full Awake(alert)

Drowsiness (Normal Stimulation)

Stupor (Painfull/Forcefull Stimulation)

Coma (Unresponsiveness) or Loss of Verbalization

↓LOC & EEG

EEG ∝ ↓LOC

EEG can determine the level of

consciuosness

NOTE:

Attention

Concentration

Acute Confussional State(↓LOC) : No At. + No Con.

Dementia : Attention Ok + No Concentration

Dementia: ↓ in COC ( not: ↓ in LOC)

TEMPORARY LOSS OF CONSCIOUSNESS

caused by: impaired cerebral perfusion (syncope,

fainting), cerebral ischemia, migraine, epileptic seizures, metabolic disturbances, sudden increases in intracranial

pressure sleep disorders.

SYNCOPE

Syncope may result from:

1. Cardiac,

2. Noncardiac

3. Undetermined causes

CARDIAC CAUSES OF SYNCOPE

decreased cardiac output secondary to cardiac arrhythmias,

outflow obstruction,

hypovolemia,

orthostatic hypotension,

decreased venous return

CEREBRAL ISCHEMIA

Cerebrovascular disturbances due to:

transient ischemic attacks of the posterior or anterior cerebral circulations,

cerebral vasospasm from migraine,

subarachnoid hemorrhage

hypertensive encephalopathy

EPILEPTIC SEIZURES

Absence seizures

Generalized tonic-clonic seizures

Complex partial seizures

SEIZURE OR SYNCOPE?

METABOLIC DISTURBANCES

Cardiac encephalopathy, hepatic encephalopathy, uremia, hypoglycemia, hypoxia, hyponatremia, hypo-/hypercalcemia, hypo-/hypermagnesemia, other electrolyte disturbances toxic and industrial exposures (carbon

monoxide, organic solvent, lead, manganese, mercury, carbon disulfide, heavy metals)

STEP BY STEP MANAGMENT

LOC Detection

6 Step Assessment

IV-Line x2

TNG

ECG

Dizepam

Refer to Specialist

باشید موفق

HEADACHE

Dr. Boroumand

USEFUL QUESTIONS سردرد نوع و تعداد سردرد شروع نحوه سردرد پریودیسیتی و فرکانس برسد خود اوج به سردرد تا کشد می طول چقدر کدامند سردرد تریگر عوامل. میکند پیشرفت چگونه و شود می شروع کجا از درد ضرباندار یا است مداوم خیر یا هست سردرد شروع برای درآمدی پیش آیا سردرد کننده تشدید عوامل. کدامند سردرد دهنده تخفیف عوامل. دارد خود سردرد علت از ای ایده چه بیمار خود

RECENT ONSET Definition:1. American Academy of Neurology

guidelines as a one-month interval.2. a 6- to 12-month interval.

“WORST EVER” HEADACHE An increasingly severe headache,

Change for the worse in an existing headache pattern

all means the possibility of an

expanding intracranial lesion.

HEADACHES OF INSTANTANEOUS ONSET Means an intracranial hemorrhage, usually in the

subarachnoid space but also can be caused by : intracerebral hemorrhage, cerebral venous thrombosis, Embolic cerebellar infarction arterial dissection, pituitary apoplexy, spontaneous intracranial hypotension, benign angiopathy of the central nervous system

(CNS), (reversible cerebral vasoconstriction syndrome)

acute hypertensive crisis, idiopathic “primary thunderclap headache”

SAH Explosive Severe Exertinal Resistant Usually with no focal neurological signs

(unless 3th nerve plasy, …) Papilledema and subhyaloid

hemorrhage. Neck stiffness

CVT (CEREBRAL VEIN THROMBOSIS) Female Hypercoagulability state (dehydration,

OCP, pregnancy, delivery) Gradual increasing headache but

sometimes suddenly onset. Resisitant to treatment May have focal neurological signs.

ATTENTION!A history of antecedent head or neck

injury should be sought; even a

relatively minor injury can be associated with:

1. the subsequent development of epidural, subdural, subarachnoid, or intraparenchymal hemorrhage

2. posttraumatic dissection of the carotid or vertebral arteries

EXERTIONAL HEADACHE AND HEADACHE ASSOCIATED WITH SEXUAL ACTIVITY BOTH ARE WORRISOME

1. A primary headache disorder unassociated with structural disease

2. can be associated with migraine

BUTThese must be excluded with the

first occurrence of such headaches. Subarachnoid hemorrhage Arterial dissection, which

CAROTID ARTERY DISSECTION

Commonly manifests with:

1. Neck, face, and head pain ipsilateral to the dissection,

2. Frequently is associated with an ipsilateral Horner's syndrome,

3. Often follows head or neck trauma

4. May cause CRA or Ophthalmic Occlusion and finally Blindness.

5. Tenderness

LOCATION AND TRIGER ZONES Asking the patient to show the location of his or

her pain with a finger often is helpful.

Trigeminal neuralgia is confined to one or more branches of the trigeminal nerve.

Lancinating face pain triggered by facial or intraoral stimuli occurs with trigeminal neuralgia. (CBZ)

Glossopharyngeal neuralgia typically is triggered

by chewing, swallowing, or talking, although cutaneous trigger zones in and about the ear occasionally are present.

HEADACHE AND FOCAL NEUROLOGICAL SIGNS Aura in Migraine Headache

Intracranial Hemorrahges

Carotid Dissection

Neuralgias

Basialr Type Migraine

GCA

MIGRAINE WITH FOCAL NEUROLOGICAL SIGNS

Aura in Migraine Headache:

Some patients with migraine have premonitory symptoms that precede a migraine headache by

hours.

These can include: 1. psychological changes, such as depression,

euphoria, or irritability, or

2. somatic symptoms, such as constipation, diarrhea, abnormal hunger, fluid retention, or increased urination.

MIGRAINE WITH FOCAL NEUROLOGICAL SIGNS–AURA focal cerebral symptoms associated with a migraine

attack. most commonly last 20 to 30 minutes but can last 1 hour. Aura symptoms usually have a gradual onset and

increase over minutes. usually precede the headache. But At other times, the

aura may continue into the headache phase or arise during the headache phase.

Visual symptoms are most common and may consist of either positive or negative phenomena or both.

Other hemispheric symptoms, such as somatosensory disturbances (numbness and/or tingling) or language dysfunction, may occur with or without visual symptoms.

If more than one symptom occurs (e.g., visual plus somatosensory), the onsets usually are staggered and not simultaneous.

3 FINDINGS WHICH CAN DIFFERENTIATE MAIGRAINE INDUCE AURA FROM CVA

1. Positive symptoms 2. the slow spread of

symptoms,

3. staggered onsets help

BASILAR TYPE MIGRAINESymptoms originating from the brainstem

or both cerebral hemispheres simultaneously, such as:

1. vertigo, 2. dysarthria, 3. ataxia, 4. auditory symptoms, 5. diplopia, 6. bilateral visual symptoms in both eyes, 7. bilateral paresthesias,8. decreased level of consciousness,

CVA The location of the pain is a poor predictor of

the vascular territory involved. cortical infarction > deep cerebral

hemisphere infarctions. either steady or throbbing and is rarely as

explosive or as severe as the headache of subarachnoid hemorrhage.

the pain is usually of at least moderate size, TIAs transient head pain in up to 40% of

patients. carotid distribution ischemia frontotemporal

head pain vertebrobasilar ischemia occipital headache.

PSEUDOTUMOR CEREBRI Female/ Obesity/Visual blur.) Drugs (/COPD/hirsutism/PCO Papilledema 6th carnial nerve paresis No special focal neurological signs No other findings in routin lab No special finding in neuroimagining LP/Prednisone/Acetazolimide

GIANT CELL ARTRITIS (TA) Most common feature: headache of an

unknown cause. most common symptom headache

(72%) The headache is most often throbbing + scalp tenderness. often generalized focal tenderness on the affected

superficial temporal > occipital artery. Fisrt step: ESR

RED FLAG OF HEADACHE New Headache Explosive headaches Worsening headaches Focal neurological sings Neck regidity Fever Trauma Inceasing pain with valsalva maneuver Confusion and decrease LOC AIDS Papilledema Old age Tenderness on the scalp Seizure Vomiting

YELLOW FLAGS OF HEADACHE

خواب از بیمار کردن بیدار باشد سر یکطرف در همیشه که سردردی. سردرد تشدید در پوسچر تغییر واضح تأثیر

VERTIGO

Dr. Boroumand

DIZZINESS Dizziness is a term patients use to describe a

variety of symptoms including:

1. spinning or movement of the environment (vertigo),

2. lightheadedness, 3. presyncope,4. Imbalance5. visual distortion, 6. internal spinning, 7. nonspecific disorientation8. anxiety

VERTIGO

sensation of spinning of the environment,

indicates a lesion within the vestibular pathways,

either peripheral or central

VERTIGO

Associated ear symptoms such as

hearing loss and tinnitus

can suggest a peripheral localization, to the inner ear or eighth nerve.

USEFUL QUESTIONS AND SIGNS Associated ear symptomes

Positional dependency

Onset pattern

Focal neurological signs

Risk factors

PHYSICAL EXAM Alertness Changes in severtiy by position

changing Blood pressure (R/o for Ortho. Hypo.) Cranial Nerve Exam (at least 5,6,7,8) Ocular motor function Ataxia Coordination tests Sensation (specially vibration) Focal neurological signs.

OCULAR MOTOR FUNCTION Peripheral pattern of nystagmus:1. A peripheral pattern of spontaneous

nystagmus is unidirectional; that is, the eyes beat only to one side.

2. It usually has a horizontal greater than torsional pattern

3. Suppression with visual fixation, 4. Increase in amplitude with gaze in the

direction of the fast phase5. Decrease with gaze in the direction

opposite that of the fast phase.

SPECIAL PHYSICAL EXAM OKN and VOR-suppression Head thrust test Positing test Fistula test Otoscopy

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