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