98 年專科護理師訓練神經系統常見問題之評估

( 二 )

意識不清 意識不清 ConfuseConfuse情緒和行為的改變 情緒和行為的改變 Mood & behavior changeMood & behavior change

成大醫院神經科 黃涵薇醫師

ConsciousnessConsciousness

Level The state of arousal

Content The quality and coherence of thought and

behavior (awareness)

thalamus

Moruzzi & Magoun, 1949

Thalamocortical radiation

Attention

Attention in both right and left aspects of extrapersonal space is governed by the "nondominant" parietal and frontal lobes.

Insight and judgment are dependent on intact higher order integrated cortical function, especially regarding frontal lobe involvement in scrutinizing incoming sensory information

High cortical function 高等皮質功能

Terms to describe consciousness

Normal (Clear) consciousness Confusion Drowsiness Stupor Coma

Confusion

A problem with coherent thinking The p’t doesn’t take into account all el

ements of his immediate environment Deficit in working memory (reduced attentio

n) “clouding of sensorium” “sun-downing phenomenon”

Missed day/night light cues Deterioration of suprachiasmatic nucleus of the hypothal

amus Disruption of REM sleep

Delirium "acute confusional state"

Drowsiness The p’t is inability to sustain a wakeful

state without the application of external stimuli

Stupor The p’t can be roused only by vigorous

and repeated stimuli Response is absent or slow and inadequate Common with restless or stereotyped motor

activity

Coma

The p’t who appears to be asleep and incapable of being aroused by external stimuli or inner need Degrees of severity : reflexes

Semicoma Sleep vs. Coma

Dilirium (DSM IV) Disturbance of consciousness with reduced ability

to focus, sustain, or shift attention. This loss of mental clarity is often subtle and may

precede more flagrant signs of delirium by one day or more ; Distractibility

A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. memory loss, disorientation, and difficulty with

language and speech The disturbance develops over a short period of

time (usually hours to days) and tends to fluctuate during the course of the day.

There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication, or medication side effect.

Additional features with delirium

Psychomotor behavioral disturbances Hyperactivity

irritability, anxiety, emotional lability, and hypersensitivity to lights and sounds

Hypoactivity quiet, withdrawn state

Increased sympathetic activity Sleep-wake reversals Variable emotional disturbances

fear, depression, euphoria, or perplexity. Delusion, hallucination

Motoric subtypes Lipowsk, 1983

Hyperactive Hypoactive

D/D with depression : circadian disturbance

Worse prognosis Mixed type

Nearly 30 percent of older medical patients experience delirium at some time during hospitalization

Patients with delirium experience prolonged hospitalizations, functional decline, and are at high risk for institutionalization.

Signs of delirium may persist for 12 months or longer, particularly in those with underlying dementia.

Mortality associated with delirium is high, approximately twice that of patients without delirium JAMA 2004;291:1753-62

Etiological factors of delirium types

Due to a general medical condition Include due to the physiological effects of a

medication Due to multiple etiologies

Include multiple general medical conditions, multiple medications, or combination

Substance-induced delirium Substance-withdrawal delirium Delirium not otherwise specified

CNS lesions & delirium (1)

P’t with preexisting CNS illness are especially vulnerable to delirium Dementia Parkinsonism MS Head trauma CNS tumors Seizure disorder Depression Alcohol or substance abuse

Acute or subacute CNS lesions or diseases are commonly associated with delirium in the acute presentation Head trauma Stroke CNS lupus Giant cell arteritis Seizures HIV complex

CNS lesions & delirium (2)

Non-CNS predisposing factors of delirium

CVD Pulmonary disease

Ischemia-hypoxia Hypercapnia

Renal disease Liver disease Local or systemic infectio

n Anemia Burns Dehydration Sensory deprivation

Poor nutritional status Electrolyte or sugar disturba

nce Sodium, phosphate Hypo/hyperglycemia

Use of physical restraints Polypharmacy Increased age and male gen

der Sleep disturbance Overall severity of the syste

mic illness Iatrogenic events (eg. Invasi

ve procedures, urinary catheterization)

Medications may lead to delirium cholinergic, dopaminergic, GABAergic, opioid-receptor function

Opioids Antihistamines Anticholinergics BZD Barbituates Other sedatives Psychotropics Anticonvulsants Antiparkinsonian

Corticosteroids Immunosuppressants CV medications GI medications Antibiotics Muscle relaxants

“DEMENTIA” D—drug and alcohol- 感冒藥水 E—electrolyte M—metabolism and nutrition, MS, B12, 葉酸 EN—endocrine and neurological disease T—tumor—NPC, hepatoma, Colon CA, pancreas I—infection 梅毒 , HIV, 感冒後 A—autoimmune disorder,such as RA

PSYCHOSIS  Hallucinations

Auditory hallucinations signify a primary psychiatric disorder, such as schizophrenia

Nonauditory hallucinations suggest psychosis in the context of a medical problem such as alcohol withdrawal

Delusions False beliefs that are firmly held despite obvious evidence t

o the contrary, and not typical of the patient's culture, faith, or family.

Thought disorganization Disruption of the logical process of thought may be represe

nted by loose associations, nonsensical speech, or bizarre behavior.

Agitation Aggression

Formal psychotic disorders Schizophrenia (DSM-IV-TR)

Schizoaffecive disorder Schizophreniform disord

er Brief psychotic disorder Delusional disorder Shared psychotic disorde

r Substance induced psych

osis Psychosis due to a gener

al medical condition Psychosis - Not otherwise

specified

Other illness may with psychosis Bipolar disorder (m

anic depression), Unipolar depressio

n Delirium Drug withdrawl

•

A psychotic individual may be able to perform actions that require a high level of intellectual effort in clear consciousness, whereas a delirious individual will have impaired memory and cognitive function

Pathophysiology of coma Morphologic

Infratentorial Brainstem -- ARAS : direct or indirect

Supratentorial Thalamus Widespread bilateral hemisphere Secondary effect on diencephalons & upper brains

tem Herniation

Metabolic Disturbance of neuronal activity

Brain Herniation

1. Transfalcial 2. Horizontal

–-- Kernohan-Woltman phenomenon

3. Transtentorial (Uncal)

4. Cerebellar tonsiller

“Duret hemorrhage”

Central syndrome of rostrocaudal deterioration

Metabolic & other diffuse disorders (65%) Supratentorial mass lesions (20%) Infratentorial lesions (13%) Psychiatric disorders (2%)

Final diagnosis in 500 p’ts admitted to hospital

with “ coma of unknown etiology” Plum & Posner (1980)

Metabolic encephalopathy

Functions subserved by complex polysynaptic pathways are affected earlier by metabolic disturbances

Asymmetric motor findings speak against the diagnosis of metabolic encephalopathy

Toxic-metabolic disorders frequently induce abnormal movements Tremor, asterixis, myoclonus, seizure

Generally, the degree of conscious disturbance parallels the reduction in cerebral metabolism/blood flow CBF

normal : 55 mL/min/100 g Coma : < 12~15 mL/min/100 g

Arterial PH Direct effects on neuronal membranes or

neurotransmitters and their receptors

Metabolic encephalopathy

Exceptions

Neurological problems without focal signs Meningitis SAH→ meningism

Metabolic problems with focal signs Hypoglycemic encephalopathy Hypertensive encephalopathy

Other related conditions (Persistent) vegetative state

Diffuse cerebral injury. Ex. Trauma, anoxia Akinetic mutism

Bilateral anterior frontal lesions Lock-in syndrome

Basis pontis lesion Brain death Catatonia Psychogenic unresponsiveness

ComaComa

Brainstem function

Focal sign

Meningism

(+) (-)

(+) (-)

(+) (-)

SAH

Meningitis

Metabolic – toxic

Supratentorial

Infratentorial

Herniation

腦葉皮質功能障礙症狀 (1) Frontal lobe 額葉

任一側 : 對側運動障礙 , 個性改變 左 : 運動型失語症 motor aphasia 兩側 : 失動 akinetic mutism, 失禁

Prietal lobe 頂葉 任一側 : 對側感覺障礙 , 對側下四分之一視野缺損 左 : 失用症 apraxia, 失讀症 alexia 右 : 忽略對側 hemineglect , 迷路

腦葉皮質功能障礙症狀 (2)

Temporal lobe 顳葉 任一側 : 對側上四分之一視野缺損 , 記憶或情緒障礙 左 : 感覺型失語症 sensory aphasia 右 : 空間觀念障礙 兩側 : 短期記憶缺損 , 冷漠

Occipital lobe 枕葉 任一側 : 對側二分之一視野缺損 , 視幻覺 左 : 辨色困難 兩側 : 皮質性失明 cortical blindness

Complex partial seizure Awake but are not in contact with others in their environ

ment and do not respond normally to instructions or questions ; often seem to stare into space

Either remain motionless or engage in repetitive behaviors, called automatisms facial grimacing, gesturing, chewing, lip smacking, snapp

ing fingers, repeating words or phrases, walking, running, or undressing.

May become hostile or aggressive if physically restrained during the event

Typically last less than three minutes Postictal phase

often characterized by somnolence, confusion, and headache for up to several hours

the patient has no memory of what took place during the seizure other than, perhaps, the aura.

Nonconvulsive status epilepticus

Transient global amnesia

Striking amnesia with preservation of other cognitive domains

Last usually several hours and are without postictal lethargy or other motor manifestations of seizures

Episodes of amnesia that are epileptic in origin will typically also include olfactory hallucinations, abnormal behaviors, and/or motor automatisms, features that are absent in TGA

Approach patients with ConfusionConfusion

焦點病史 Ascertain the patient's level of functi

oning prior to the onset of conscious problem

Onset, duration, course Associated Symptoms

Life event? Head trauma? Insomnia? Sleepy? Headache/dizziness? Appetite? Vomiting/diarrhea? Fever? Palpitations? Dyspnea? Staggering or ataxic gait? Double vision? Slu

rred speech? Numbness / weakness of the face or body? Clumsiness, or incoordination?

Medications / Substance

焦點身體檢查 Physical examination

T/P/R and BP Skin Eyes: conjunctiva pale/icteric or not Breathing sound Bowel sound Bladder palpation

Eye opening 4 : spontaneous 3 : to speech 2: to pain 1: none

Verbal response 5 : oriented 4: confused 3: words 2: sounds 1: none

Motor response 6: obey commands 5: localizing to pain 4: withdrawal from pain 3: flexion to pain 2: extension to pain 1: none

Glasgow coma scale(Teasdale & Jennett, 1977)

VA: aphasia

VT: trachea

Aphasia?

Dysarthria?

To check “Attention”

Digit span Inability to repeat a string of at least 5 digits i

ndicates probable impairment Vigilance “A” test ( 逢 3 舉手 )

Read a list of 60 letters, among which the letter "A" appears with greater than random frequency.

More than 2 errors is considered abnormal.

Conscious ContentContent evaluation

JOMAC Judgment: 失火了要怎麼辦 ? Orientation: 人 , 時 , 地 Memory: 短期 (ex.3 objects in 5 minute

s), 長期 (ex. 住址 ) Abstract thinking: 比較物體 / 成語解釋 Calculation (ex. 100-7 series, 20-3 serie

s)

不識字 小學識字

中學畢業

50-69 y/o

≤16 ≤ 20 ≤ 24

≥70 y/o

≤ 14 ≤ 19 ≤ 23

Localization : Focal sign or not ? Brainstem reflexes

Pupils / light reflex Eye position, EOM Corneal reflex Oculocephalic reflex (Doll’s eye sign) Oculovestibular reflex Respiratory patterns Gag reflex

Long tract sign Muscle power (asymmetry?) Babinski sign

中腦III 動眼 , IV 滑車 , VI 外展

橋腦V 三叉 , VII 顏面 , VIII 聽平衡

延腦IX 舌咽 , X 迷走 , XI 副 , XII 舌下

Pupils & Light reflex

tegmentum,irregular

,reactive

Hypothalamus miosis

Spontaneous eye movement in comatose patients

Periodic alternating gaze (ping-pong gaze) Bilateral cerebral damage, rarely posterior fossa lesion

Repetitive divergence Metabolic encephalopathy

Ocular bobbing Pontine, extra-axial posterior fossa mass, diffuse encephalop

athy Ocular dipping

Anoxia, post-status epilepticus Nystagmoid jerking of a single eye

Middle or low pontineRoving eye movement

Conjugate gaze Hemispheric lesion (frontal eye field)

Look to lesion side Lower pontine tegmentum

Look away from lesion side Disconjugate gaze

MLF syndrome Skew deviation

Eye movement - abnormality of gaze

Horizontal Gaze pathway

Contralateral Frontal eye field (area 8)

PPRF

視野檢查

Confrontation test(Threaten test)

V 三叉神經 顏面感覺

V1, V2, V3 咀嚼肌

是否對稱 角膜反射

< 五進七出 > Corneal reflex: +/+

V1

V2

V3

Left

Peripheral facial palsy

額頭皺紋

用力閉眼

展示牙齒

Right

Central facial palsy

IX, X 嘔吐反射

Gag reflex +/+ Soft palate elevation

XI SCM, trapezius muscle

XII Tongue protruding

R’t

R’t

Respiratory patterns

Ondine’s Curse

(Biot)

Brainstem reflex 腦幹反射 中腦

Pupil size, Light reflex 橋腦

Corneal reflex Doll’s eye sign

延腦 Breathing Cardiovascular center

Tentorium

A coma patient with right hemiplegia

Babinski sign

血液檢查 CBC/DC, Biochemistry, ABG, drug penal…

EEG Disappearance of alpha rhythm Slow waves Triphasic waves Diffuse epileptiform discharge “Alpha coma”

影像學檢查 對於顱內出血的病灶 CT 優於 MRI 對於後顱窩的病灶 MRI 優於 CT

實驗室與診斷檢查

處置 治療相關致病因素 維持正常生命徵象 依需求補充體液電解質 低劑量的精神安定劑 非藥物處置

限制日間睡眠 / 增加日光照射時間 / 安排適當活動 視需要給予適當之約束 幻覺之護理：一對一照顧，環境要單純 溝通簡短扼要，重複提供現實導向 Environmental modification Soft lighting, music, elimination of stressful stimuli.

Confusion - Cases discussion

Case 1 81 y/o female No systemic disease, ADL independent 2 days ago, woke up in AM 4:00 as usual Felt mild general discomfort, but still walk t

o the market Couldn’t find the way to the market Walked “home” again Family found her on the way to the old hous

e, and the patient was mild dull in response; couldn’t hold the bowel well by left hand

Conscious clear PE: normal NE

JOMAC: intact Left homonymous hemianopia (inferior domi

nant) DSS: Left hemineglect Left hemiparesis (5-)

Right parietal infarct (MCA infarct)

Case 2 67 y/o male, with history of DM, H/T and G

U Baseline: ADL independent, but seems bec

ame forgetful in recent 2-3 years Low back pain for 1 month, Tx in LMDs 3 days ago, the p’t developed bizarre beh

avior, worse in nights 說有朋友來拜訪 ( 朋友其實已往生 ) 說有小孩子在旁邊玩 吃衛生紙

No headache, no fever No dysarthria, dysphagia, diplopia

Vital signs: BP: 150/90 mmHg, T/P/R: 36.9/75/18

PE normal NE

Sleepy Conscious: E3V4M5-6

Orientation to person: 經提示後問了好幾次才答對 , orientation to time OK, to place: fail

Cranial nerves: normal Mild right limbs spasticity MP, sensory & coordination: fair

Lab: not contributory

Multiple small old infarcts with white matter change and mild brain atrophy

Suspect drug-induced delirium OBS Conscious level improved gradually Less visual hallucination

5 days after admission Vital sign normal Conscious: E4V5M6 Orientation to time, person, place OK 跟醫生說昨天晚上很累 , 因為和兒子去郵局辦事 ,

碰到警匪槍戰 , 一直在躲流彈

Lab WBC 10.1 K/ mm3, seg 90% Biochemistry normal U/A WBC 13-15, nitrate(+), bacteria(++)

Fever up to 39ºC that night U/C, B/C : E. coli

Cognition return to baseline 2 days after antibiotics treatment

Thanks For Your Thanks For Your Attention ~Attention ~