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Consciousness Disturbance
原著: 林光麟 醫師
網頁編輯: 麥建方醫師 |
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在急診或加護病房第一線的醫師遇到consciousness
disturbance 的病人，需要鎮定而迅速地做評估，然後維持vital
sign，再做後續的治療與檢查。 |
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 緊急處理及評估
再一次檢查
治療
Modified Glasgow Coma
Scale |
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緊急處理及評估
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A. Stabilize
vital signs
| 1. |
Stabilize C-spine |
| 2. |
Secure Airway,
Breathing, Circulation |
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B. Glasgow coma scale
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1. |
History: |
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Witness, disease history, onset, preceding complaints, trauma,
medications and toxin at home |
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初步評估找出可能原因： |
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 瞳孔大小、反應，尋找other
evidence of lateralization
測量呼吸pattern,
rate, BP, pulse, temperature, O2 saturation
DTR,
Reflexes |
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C. Baseline
investigation
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| CBC/DC
, electrolyte, creatinine, ABG , glucose(F/S), Liver function,
PT/ APTT , NH3 , toxic screen(if available) |
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如有infection sign應作Blood
culture |
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CSF的study
應特別小心Do not undertake lumbar puncture in
if there is evidence of IICP, focal neurological signs, a purpuric
rash, abnormal posturing, papilla edema, hypertension, coagulopathyA. |
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Consider giving
glucose(2ml/kg of25% dextrose) if F/S or results of blood glucose are not
immediately available
* ER
醫師應注意早上或清晨小孩不明原因意識不清,在ER要特別注意Blood
sugar (Ketotic hypoglycemia) |
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再一次檢查
病人初步穩定後的後續動作－－再一次檢查，尋找原因及治療
| A. |
Full
examination |
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1. Look for the following
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Signs of trauma |
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Neck stiffness, Kernig's sign |
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Pallor in shock or hemo1ysis |
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Ear/nose: clear or blood-stained , CSF discharge, otitis media |
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Hepatomegaly (Reye syndrome ) |
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Funduscopy for hemorrhage and papilla edema |
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2 Neurological assessment
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Supratentorial
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* Focal cerebral dysfunction |
* Rostro caudal progression |
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* Asymmetric motor signs |
* Abnormal pupillary reaction |
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Subtentorial
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* Sudden onset |
* Abnormal cold calorie test |
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* doll's eyes reflexes |
* CN palsies |
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* Abnormal respiratory patterns |
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Psychiatric
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* Pupils normal or dilated |
* Unpredictable ocular reflexes |
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* Hyperventilation |
* No pathologic reflexes |
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* Eyelids close actively |
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Metabolic
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* Preceding confusion or stupor |
* Symmetrical motor signs |
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* Normal pupillary reflexes |
* Myoclonus, tremor or seizures |
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* Acid-base imbalance |
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3.Indications for urgent brain CT
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Suspected trauma |
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Bleeding disorders |
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Focal neurologia signs |
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IICP |
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Suspected intracranial mass |
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[Top] |
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治療：
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A. |
Patients with a GCS~8 should
beadmitted to the ICU |
| B. |
Maintenance of optimal heart
rate,systemic BP, respiratory status |
| C. |
Correct accompanying
metabolicdisturbance |
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| Hypoglycemia |
| Hypo or hypernatremia (應注意病人的 fluid
status,不可快速correct ) |
| Acid-base imbalance· respiratory ·
metabolic acidosis |
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| D. |
IICP如果有
infection signs ,病人stable 後立刻給予Antibiotics。
例如；皮膚有
purpuric skin rash 懷疑meningococcal septicemia；
發燒且有 Neck
stiffness 懷疑meningitis |
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[Top] |
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Modified Glasgow Coma Scale
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Eyes Opening
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Score
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＞1yo
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＜1yo
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4
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Spontaneously
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Spontaneously
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3
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To verbal command
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To shout
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2
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To pain
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To pain
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1
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No response
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No response
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Best motor response
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Score
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＞1yo
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＜1yo
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6
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Obeys
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Spontaneously
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5
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Localizes pain
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Localizes pain
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4
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Flexion-withdrawal
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Flexion-withdrawal
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3
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Flexion-abnormal
(decorticate rigidity)
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Flexion-abnormal
(decorticate rigidity)
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2
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Extension
(decerebrate rigidity)
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Extension
(decerebrate rigidity)
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1
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No response
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No response
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Best verbal response
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score
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＞5yo
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2-5yo
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0-23mo
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5
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Oriented and converses
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Appropriate and phrases
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Smile, coos appropriately
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4
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Disoriented and converses
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Inappropriate words
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Cries, consolable
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3
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Inappropriate words
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Persistent cries or screams
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Persistent inappropriate crying or screaming
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2
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Incomprehensible sounds
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Grunts
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Grunts, agitated or restless
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1
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No response
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No response
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No response
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