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DIAH MUSTIKA HW SpS,KIC
Intensive Care Unit of Emergency Department
Naval Hospital dr RAMELAN , Surabaya
Encephalopathy is a common complication of
systemic illness or direct brain injury.
Acute confusional state, acute organic brain
syndrome, acute cerebral insufficiency
most commonly as delirium
Acute alteration of consciousness and higher
cognitive function
Develops over a short of period time
Fluctuating course
Precipitated by several diverse pathological
process
DSM –IV TR
Incidence 5%-40% in general hospitalized
patient and 11%- 80% in critically ill
a. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, to sustain, or to shift attention.
b. A change in cognition (such as memory deficit, disorientation, or language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexistin, estabilished or evolving dementia.
c. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
d. There is evidence from the history, physical examination, or laboratory findings thet the disturbance is caused by the direct physiologic condequences of a general medical condition.
From American Psychiatric Association. Task Force on DSM-IV.
Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, 4th
ed. Washington, DC: American Psychiatric Association; 2000
Age > 70 years
Male
Poor functional status
Malnutrition
Substance abuse
Premorbid medical conditions or cognitive impairment
Polypharmacy
Physycal restraint
Visual or hearing impairment
Prior history of delirium
Vascular Ischemic stroke, transient ischemic attack, subarachnoid
hemorrhage, intracerebral hemorrhage, epidural
hematoma, subdural hematoma, cerebal venous
thrombosis, myocardial infarction, pulmonary embolism,
extreme hypertension/hypotension.
Infectious Meningitis, encephalitis, cerebral abcess, neurosyphilis,
Lyme disease, systemic sepsis, HIV infection and
complications, pneumonia, urinary tract infection.
Inflammatory CNS lupus erythematosus, Giant cell arteritis,
neurosarcoidosis.
Neoplastic Systemic cancer, paraneoplastic syndromes, CNS tumors,
carcinomatous meningitis.
Legal and illegal
drugs
Anticholinergics, narcotics, benzodiazepines, barbiturates,
anesthetic, digitals, corticosteroids, antiparkinsonian,
antiepileptics , immunosuppressants (tacrolimus),
recreational drugs (abuse or withdrawal), over-the-counter
medications, herbal preparations.
Recent surgery Cardiac, orthopedic, CNS surgery, other invasive
precedures.
Trauma Traumatic brain injury, multiple organ trauma, air or fat
embolism.
Metabolic Liver failure, uremia, hypoglycemia, hyperglycemia,
electrolyte abnormalities, hypercarbia, hypoxia.
Endocrine Thyroid, parathyroid, pituitary, adrenal gland dysfunction,
uncontrolled diabetes, pancreatitis.
Epileptic Postictal conditions, status epilepticus (convulsive or
nonconvulsive)
Nutritional Thiamine, B12, folic acid deficiencies
Hereditary Mitochondrial disorders (MELAS)
Miscellaneous Anaemia, dehydration, volume overload, burns, chronic
obstructive pulmonary disease (COPD), migraine, sensory
deprivation, sleep deprivation, posterior reversible
encephalopayh syndrome, Reye syndrome.
Alteration of consciousness impairment of
arousal : paradoxical agitation to sedation and
stupor
Attention impairment
Fluctuation of symptomatology
Hallucination, disorientation and perceptual
distortion. Visual hallucination and illusions may
result in attempt to dislidge to ET or IV lines
Disorganized thinking
1. The Confusion Assessment Metod for the
Intensive Care Unit (CAM-ICU)
2. The Intensive Care Delirium Screening
Checklist
History
Clinical Examination : general and neurologic
clinical examination
Laboratory investigations
Electrocardiogram
Chest X ray
Electroencephalogram
Computed tomography of the brain
Primary prevention of delirium
Identification of patient at high risk for
developing delirium
Early detection of syndrome
Identification and treatment of
underlying etiologies
Environmental modifications,
nonpharmacologic management
Symptomatic pharmacologic management
Mechanical Ventilation
Drugs Dose Comments
Haloperidol Younger patients 2-5 mg IV q2h Older patients 0.5-1 mg IV q2h
Extrapyramidal side effect QTc prolongation
Risperidone Younger patients 0.75-3 mg PO/day Older patients 0.25-0.5 mg PO q12h
Can induce delirium QTc prolongation
Olanzapine Younger patients 3-7.5 mg PO/day Older patients 2.5-5 mg PO at night
Not to be used with age >70 years Increases glucose levels Less QTc prolongation
Quetiapine Younger patients 25-100 mg PO/day Older patients 12.5 mg PO at night
QTc prolongation, but can be used following haloperidol-induced prolonged QTc
Lorazepam 0.5-2 mg IV/PO q8h Monitor sedation level and respiratory rate.
Encephalopathy is a index of acute CNS
dysfunction
Precipitated by multiple underlying disease
should be actively treated
Neurologic damage my progress to coma if
untreated
Effective management is multimodal and
requires coordination of the team