Download 98年專科護理師訓練 神經系統常見問題之評估 (一)

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 Confuse
情緒和行為的改變
Mood & behavior change
成大醫院神經科
黃涵薇醫師
Consciousness

Level


The state of arousal
Content

The quality and coherence of thought and behavior
(awareness)
Thalamocortical
radiation
thalamus
Moruzzi & Magoun, 1949
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

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Normal (Clear) consciousness
Confusion
Drowsiness
Stupor
Coma
Confusion


A problem with coherent thinking
The p’t doesn’t take into account all elements of his
immediate environment

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Deficit in working memory (reduced attention)
“clouding of sensorium”
“sun-downing phenomenon”
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Missed day/night light cues
Deterioration of suprachiasmatic nucleus of the hypothalamus
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.


A change in cognition or the development of a perceptual
disturbance that is not better accounted for by a preexisting,
established, or evolving dementia.



This loss of mental clarity is often subtle and may precede more
flagrant signs of delirium by one day or more ; Distractibility
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



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Increased sympathetic activity
Sleep-wake reversals
Variable emotional disturbances

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fear, depression, euphoria, or perplexity.
Delusion, hallucination
Motoric subtypes

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Hyperactive
Hypoactive

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
Lipowsk, 1983
D/D with depression : circadian disturbance
Worse prognosis
Mixed type

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

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


Due to multiple etiologies

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
Include due to the physiological effects of a medication
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

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Dementia
Parkinsonism
MS
Head trauma
CNS tumors
Seizure disorder
Depression
Alcohol or substance abuse
CNS lesions & delirium (2)

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

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
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Non-CNS predisposing factors of
delirium
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CVD
Pulmonary disease
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Ischemia-hypoxia
Hypercapnia
Renal disease
Liver disease
Local or systemic infection
Anemia
Burns
Dehydration
Sensory deprivation
Poor nutritional status
Electrolyte or sugar disturbance

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Sodium, phosphate
Hypo/hyperglycemia
Use of physical restraints
Polypharmacy
Increased age and male gender
Sleep disturbance
Overall severity of the systemic
illness
Iatrogenic events (eg. Invasive
procedures, urinary
catheterization)
Medications may lead to delirium
cholinergic, dopaminergic, GABAergic,
opioid-receptor function

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Opioids
Antihistamines
Anticholinergics
BZD
Barbituates
Other sedatives
Psychotropics
Anticonvulsants
Antiparkinsonian




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Corticosteroids
Immunosuppressants
CV medications
GI medications
Antibiotics
Muscle relaxants
“DEMENTIA”

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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

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
Delusions


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False beliefs that are firmly held despite obvious evidence to the
contrary, and not typical of the patient's culture, faith, or family.
Thought disorganization


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
Disruption of the logical process of thought may be represented by
loose associations, nonsensical speech, or bizarre behavior.
Agitation
Aggression
•
Formal psychotic
disorders Schizophrenia
(DSM-IV-TR)

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Schizoaffecive disorder
Schizophreniform disorder
Brief psychotic disorder
Delusional disorder
Shared psychotic disorder
Substance induced
psychosis
Psychosis due to a general
medical condition
Psychosis - Not otherwise
specified

Other illness may
with psychosis



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Bipolar disorder
(manic depression),
Unipolar depression
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

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Thalamus
Widespread bilateral hemisphere
Secondary effect on diencephalons & upper brainstem


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
Final diagnosis in 500 p’ts
admitted to hospital
with “ coma of unknown etiology”
Plum & Posner (1980)

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Metabolic & other diffuse disorders (65%)
Supratentorial mass lesions (20%)
Infratentorial lesions (13%)
Psychiatric disorders (2%)
Metabolic encephalopathy


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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
Metabolic encephalopathy

Generally, the degree of conscious disturbance
parallels the reduction in cerebral
metabolism/blood flow

CBF

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

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
Exceptions

Neurological problems without focal signs
Meningitis
 SAH
→ meningism

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Metabolic problems with focal signs
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Hypoglycemic encephalopathy
Hypertensive encephalopathy
Other related conditions
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(Persistent) vegetative state
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Akinetic mutism
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Bilateral anterior frontal lesions
Lock-in syndrome
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Diffuse cerebral injury. Ex. Trauma, anoxia
Basis pontis lesion
Brain death
Catatonia
Psychogenic unresponsiveness
Coma
Brainstem function
(-)
(+)
Focal sign
(-)
(+)
Supratentorial
Infratentorial
Herniation
Meningism
(+)
SAH
Meningitis
(-)
Metabolic
– toxic
腦葉皮質功能障礙症狀(1)

Frontal lobe 額葉

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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

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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

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
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

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Awake but are not in contact with others in their environment 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, snapping 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
Confusion
焦點病史


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Ascertain the patient's level of functioning
prior to the onset of conscious problem
Onset, duration, course
Associated Symptoms

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

Life event? Head trauma?
Insomnia? Sleepy? Headache/dizziness?
Appetite? Vomiting/diarrhea?
Fever? Palpitations? Dyspnea?
Staggering or ataxic gait? Double vision? Slurred
speech? Numbness / weakness of the face or body?
Clumsiness, or incoordination?
Medications / Substance
焦點身體檢查

Physical examination
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T/P/R and BP
Skin
Eyes: conjunctiva pale/icteric or not
Breathing sound
Bowel sound
Bladder palpation
Glasgow coma scale
(Teasdale & Jennett, 1977)

Eye opening
Motor response
4 : spontaneous
3 : to speech
2: to pain
1: none

Verbal response

5 : oriented
4: confused
3: words
2: sounds
1: none
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6: obey commands
5: localizing to pain
4: withdrawal from pain
3: flexion to pain
2: extension to pain
1: none
VA: aphasia
Aphasia?
VT: trachea
Dysarthria?
To check “Attention”

Digit span


Inability to repeat a string of at least 5 digits indicates
probable impairment
Vigilance “A” test (逢3舉手)

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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 Content evaluation

JOMAC
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Judgment: 失火了要怎麼辦?
Orientation: 人, 時, 地
Memory: 短期(ex.3 objects in 5 minutes),
長期(ex.住址)
Abstract thinking: 比較物體/成語解釋
Calculation (ex. 100-7 series, 20-3 series)
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 ?
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Brainstem reflexes
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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
,reactive
Hypothalamus
miosis
tegmentum
,irregular
Spontaneous eye movement in
comatose patients

Periodic alternating gaze (ping-pong gaze)

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Repetitive divergence

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Pontine, extra-axial posterior fossa mass, diffuse encephalopathy
Ocular dipping

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Metabolic encephalopathy
Ocular bobbing

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Bilateral cerebral damage, rarely posterior fossa lesion
Anoxia, post-status epilepticus
Nystagmoid jerking of a single eye

Middle or low pontine
Roving eye movement
Eye movement
- abnormality of gaze

Conjugate gaze

Hemispheric lesion (frontal eye field)

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Lower pontine tegmentum


Look to lesion side
Look away from lesion side
Disconjugate gaze

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MLF syndrome
Skew deviation
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


V1
<五進七出>
Corneal reflex: +/+
V2
V3
額頭皺紋
用力閉眼
展示牙齒
Left
Peripheral facial palsy
Right
Central facial palsy

IX, X

嘔吐反射



Gag reflex +/+
Soft palate elevation
XI


R’t
SCM, trapezius muscle
XII

Tongue protruding
R’t
Respiratory patterns
(Biot)
Ondine’s Curse
Brainstem reflex 腦幹反射

中腦
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
橋腦
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Pupil size, Light reflex
Corneal reflex
Doll’s eye sign
延腦


Breathing
Cardiovascular center
Tentorium

A coma patient with right hemiplegia
Babinski sign
實驗室與診斷檢查

血液檢查
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EEG
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CBC/DC, Biochemistry, ABG, drug penal…
Disappearance of alpha rhythm
Slow waves
Triphasic waves
Diffuse epileptiform discharge
“Alpha coma”
影像學檢查
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
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
處置
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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
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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
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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 to the
market
Couldn’t find the way to the market
Walked “home” again
Family found her on the way to the old house, and
the patient was mild dull in response; couldn’t hold
the bowel well by left hand

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
Conscious clear
PE: normal
NE




JOMAC: intact
Left homonymous hemianopia (inferior dominant)
DSS: Left hemineglect
Left hemiparesis (5-)
Right parietal infarct (MCA infarct)
Case 2
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
67 y/o male, with history of DM, H/T and GU
Baseline: ADL independent, but seems became
forgetful in recent 2-3 years
Low back pain for 1 month, Tx in LMDs
3 days ago, the p’t developed bizarre behavior,
worse in nights

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


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

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Sleepy
Conscious: E3V4M5-6
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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
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OBS
Conscious level improved gradually
Less visual hallucination
5 days after admission
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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
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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
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