診斷學常見癥狀-意識障礙

意識障礙

Disturbanceofconsciousness定義

Definition意識障礙：是指人對周圍環(huán)境及自身狀態(tài)的識別和覺察能力出現(xiàn)障礙。Disturbanceofconsciousnessisdysfunctionoftheabilitythatallowanindividualtoperceive,comprehendandactontheinternalandexternalenvironments.2病因

Etiology1重癥急性感染：敗血癥，肺炎，痢疾、傷寒、顱腦感染1Severeacuteinfection:sepsis,pneumonia,dysentery,typhoid,braininfection2顱腦非感染性疾?。耗X血管病，腦占位性疾病，顱腦損傷，癲癇2Brainnon-infectiousdiseases:cerebrovasculardiseases,braintumordiseases,braininjury,epilepsy3內(nèi)分泌與代謝障礙：尿毒癥，肝性腦病，肺性腦病，糖尿病性昏迷3Endocrineandmetabolicdisorders:uremia,hepaticencephalopathy,pulmonaryencephalopathy,diabeticcoma4心血管疾?。褐囟刃菘耍囟刃穆墒С?，阿-斯綜合征4Cardiovasculardiseases:Severeshock,severearrythmia,Adams-Stokessyndrome3病因

Etiology5水電解質(zhì)平衡紊亂waterfactorandelectrolyteimbalance:水中毒，低鈉血癥waterintoxication,hyponatremia

6外源性中毒Exogenouspoisoning:酒精中毒alcoholicintoxication7物理性及缺氧性損害physicalandanoxicdamages：中暑，觸電heatshock,electricshock4發(fā)生機制意識內(nèi)容：大腦皮質(zhì)功能活動“開關”系統(tǒng)：特異性上行投射系統(tǒng)（經(jīng)典感覺傳導路徑）非特異性上行投射系統(tǒng)（腦干網(wǎng)狀結(jié)構(gòu)）由于腦部缺氧、缺血、葡萄糖供給不足、酶代謝異常等因素致腦代謝紊亂5Consciousnessreferstoasetofneuralprocessesthatallowanindividualtoperceive,comprehend,andactontheinternalandexternalenvironments.Itconsistsoftwocomponents:awarenessandarousal.Awarenessreferstothehigher-levelintegrationofmultiplesensoryinputsthatpermitmeaningfulunderstandingselfandenvironment,residinginthecerebralcortex.Arousalreferstoan“on-offswitch”forthecorticalawarenesssystembyascendingreticularactivatingsystem(ARAS),residinginthebrainstem.Anyinjuriesinvolvingbothbilateraldiffusecerebralcortexand/orbrainstemcancausedisturbanceofconsciousness.發(fā)生機制

Pathophysiology6臨床表現(xiàn)

ClinicalmanifestationDisturbancesofconsciousnesscanbeclassifiedaccordingtodegree,fromminortosevere:1嗜睡somnolence:最輕的意識障礙，病理性倦睡，可喚醒，正確回答和反應，停止刺激則入睡It’sthelightestdisturbancesofconsciousness,pathologytiredsleep,canbeawaken,cangivethecorrectreplyandresponse,butgotosleepafterstopingthestimulation7臨床表現(xiàn)

Clinicalmanifestation2意識模糊confusion:患者保持簡單的精神活動，但對時間，地點，人物的定向力發(fā)生障礙。Thepatientmaintainsthesimplespiritualactivity,buthasthedisturbancestotheorientationoftime,placeandperson.3昏睡stupor:患者處于熟睡狀態(tài)，不易喚醒，雖在強烈刺激下可被喚醒，但很快又在入睡。醒時答話含糊或答非所問。Thepatientisatdeepsleepcondition,noteasytobeawaken,althoughawakenundertheintensestimulationandwithambiguousorirrelevantlyreplies,butgoingtosleepveryquickly.84昏迷coma：嚴重的意識障礙，意識持續(xù)的中斷或完全喪失It’stheseriousdisturbancesofconsciousness,consciousnessretainsinterruptedorevenlosescompletely.(1)輕度昏迷mildcoma：無自主活動，對聲光刺激無反應，對疼痛刺激有痛苦表情或肢體退縮等防御性反應；生理反射可存在。It’snospontaneousactivity,noresponsetothesound-opticstimulation,havingthedefensiveresponses(painfulexpressionorwithdrawallimbs)totheachestimulation,thephysiologicalreflectionmayexist.

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(2)中度昏迷moderatecoma：對周圍事物及各種刺激均無反應，對于劇烈刺激或可出現(xiàn)防御性反射，各種生理反射減弱或遲鈍，眼球無轉(zhuǎn)動。Ithasnoresponsetothesurroundingsandallkindsofstimulation,ormaypresentthedefensivereflexregardingthefiercestimulation,eachphysiologicalreflectionisweakenorslow,theeyeballdoesnothavetherotation.(3)深度昏迷deepcoma：全身肌肉松弛，刺激無反應，深淺反射均消失Thewholebodymuscleisrelaxation,noresponsetoanystimulation,norshallowreflectionanddeepreflection.10譫妄delirium:意識模糊,定向力喪失,感覺錯亂,躁動不安,言語雜亂aspeicaldisturbanceofconsciousnesswithincreasedexcitability.Forthepatient,awarenessisfuzzy,theorientationabilityloses,feelingisconfused,moveisrestless,spokenwordsisdisorderly.11伴隨癥狀

Accompanyingsymptoms發(fā)熱fever先發(fā)熱后意識障礙、先意識障礙后發(fā)熱呼吸緩慢bradypnea藥物中毒瞳孔散大mydriasis顛茄類、酒精、氰化物瞳孔縮小myosis嗎啡、巴比妥類、有機磷心動過緩bradycardia顱內(nèi)高壓、心臟病高血壓hypertension高血壓腦病、腦血管意外、尿毒癥低血壓hypotension休克皮膚粘膜改變mucocutaneouschanges嚴重感染、CO腦膜刺激征meningealirritation腦膜炎

蛛網(wǎng)膜下腔出血12

中年以上，有高血壓病史，活動時發(fā)病，突感頭痛、嘔吐、昏迷、鼾聲呼吸，偏癱。頭顱MR腦出血突感劇烈頭痛，嘔吐，即之昏迷，頸有抵抗，克尼格氏征陽性腰穿，頭顱MR、腦血管造影蛛網(wǎng)膜下腔出血既往有心臟病史，特別是風心病心房纖顫著，突然抽搐、偏癱、昏迷頭顱MR

心電圖腦栓塞昏迷不醒，有似深睡狀態(tài)，四肢松軟、瞳孔縮小

深入了解病人有無心理障礙，尋找藥瓶，遺書.安眠藥中毒急性起病，高熱、劇烈頭痛、嘔吐、昏迷、頸項強直血常規(guī)，腦脊液檢查化膿性腦膜炎急性起病的昏迷13

冬季發(fā)病，有一氧化碳中毒的可能環(huán)境，晨起被發(fā)現(xiàn)，昏迷、口唇成櫻桃紅色，面色潮紅血清碳氧血紅蛋白測定一氧化碳中毒用胰島素治療的糖尿病人，在飲食不當、胰島素用量過大，出現(xiàn)心悸、出汗、無力、面色蒼白、血壓下降尿常規(guī)、血糖測定低血糖昏迷中年以上，有動脈硬化史，安靜狀態(tài)下發(fā)病，現(xiàn)有肢體活動不利，逐漸癱瘓或有一過性黑蒙，惡心、嘔吐、昏迷頭顱MR腦血栓形成青年、兒童，有結(jié)核病史，發(fā)熱、頭痛、惡心、嘔吐、逐漸昏迷、頸項強直，克尼格氏征陽性胸片、腦脊液檢查結(jié)核性腦膜炎糖尿病病史，飲食控制不當，飲酒、感染后出現(xiàn)惡心、嘔吐、呼吸深大，呼氣有爛蘋果味血糖、酮體測定，尿糖、尿酮體，血氣分析糖尿病昏迷亞急性起病的昏迷14

有慢性腎炎或高血壓病史，食欲減退，惡心、嘔吐