诊断学常见症状-意识障碍

意识障碍

Disturbanceofconsciousness定义

Definition意识障碍：是指人对周围环境及自身状态的识别和觉察能力出现障碍。Disturbanceofconsciousnessisdysfunctionoftheabilitythatallowanindividualtoperceive,comprehendandactontheinternalandexternalenvironments.2病因

Etiology1重症急性感染：败血症，肺炎，痢疾、伤寒、颅脑感染1Severeacuteinfection:sepsis,pneumonia,dysentery,typhoid,braininfection2颅脑非感染性疾病：脑血管病，脑占位性疾病，颅脑损伤，癫痫2Brainnon-infectiousdiseases:cerebrovasculardiseases,braintumordiseases,braininjury,epilepsy3内分泌与代谢障碍：尿毒症，肝性脑病，肺性脑病，糖尿病性昏迷3Endocrineandmetabolicdisorders:uremia,hepaticencephalopathy,pulmonaryencephalopathy,diabeticcoma4心血管疾病：重度休克，重度心律失常，阿-斯综合征4Cardiovasculardiseases:Severeshock,severearrythmia,Adams-Stokessyndrome3病因

Etiology5水电解质平衡紊乱waterfactorandelectrolyteimbalance:水中毒，低钠血症waterintoxication,hyponatremia

6外源性中毒Exogenouspoisoning:酒精中毒alcoholicintoxication7物理性及缺氧性损害physicalandanoxicdamages：中暑，触电heatshock,electricshock4发生机制意识内容：大脑皮质功能活动“开关”系统：特异性上行投射系统（经典感觉传导路径）非特异性上行投射系统（脑干网状结构）由于脑部缺氧、缺血、葡萄糖供给不足、酶代谢异常等因素致脑代谢紊乱5Consciousnessreferstoasetofneuralprocessesthatallowanindividualtoperceive,comprehend,andactontheinternalandexternalenvironments.Itconsistsoftwocomponents:awarenessandarousal.Awarenessreferstothehigher-levelintegrationofmultiplesensoryinputsthatpermitmeaningfulunderstandingselfandenvironment,residinginthecerebralcortex.Arousalreferstoan“on-offswitch”forthecorticalawarenesssystembyascendingreticularactivatingsystem(ARAS),residinginthebrainstem.Anyinjuriesinvolvingbothbilateraldiffusecerebralcortexand/orbrainstemcancausedisturbanceofconsciousness.发生机制

Pathophysiology6临床表现

ClinicalmanifestationDisturbancesofconsciousnesscanbeclassifiedaccordingtodegree,fromminortosevere:1嗜睡somnolence:最轻的意识障碍，病理性倦睡，可唤醒，正确回答和反应，停止刺激则入睡It’sthelightestdisturbancesofconsciousness,pathologytiredsleep,canbeawaken,cangivethecorrectreplyandresponse,butgotosleepafterstopingthestimulation7临床表现

Clinicalmanifestation2意识模糊confusion:患者保持简单的精神活动，但对时间，地点，人物的定向力发生障碍。Thepatientmaintainsthesimplespiritualactivity,buthasthedisturbancestotheorientationoftime,placeandperson.3昏睡stupor:患者处于熟睡状态，不易唤醒，虽在强烈刺激下可被唤醒，但很快又在入睡。醒时答话含糊或答非所问。Thepatientisatdeepsleepcondition,noteasytobeawaken,althoughawakenundertheintensestimulationandwithambiguousorirrelevantlyreplies,butgoingtosleepveryquickly.84昏迷coma：严重的意识障碍，意识持续的中断或完全丧失It’stheseriousdisturbancesofconsciousness,consciousnessretainsinterruptedorevenlosescompletely.(1)轻度昏迷mildcoma：无自主活动，对声光刺激无反应，对疼痛刺激有痛苦表情或肢体退缩等防御性反应；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：对周围事物及各种刺激均无反应，对于剧烈刺激或可出现防御性反射，各种生理反射减弱或迟钝，眼球无转动。Ithasnoresponsetothesurroundingsandallkindsofstimulation,ormaypresentthedefensivereflexregardingthefiercestimulation,eachphysiologicalreflectionisweakenorslow,theeyeballdoesnothavetherotation.(3)深度昏迷deepcoma：全身肌肉松弛，刺激无反应，深浅反射均消失Thewholebodymuscleisrelaxation,noresponsetoanystimulation,norshallowreflectionanddeepreflection.10谵妄delirium:意识模糊,定向力丧失,感觉错乱,躁动不安,言语杂乱aspeicaldisturbanceofconsciousnesswithincreasedexcitability.Forthepatient,awarenessisfuzzy,theorientationabilityloses,feelingisconfused,moveisrestless,spokenwordsisdisorderly.11伴随症状

Accompanyingsymptoms发热fever先发热后意识障碍、先意识障碍后发热呼吸缓慢bradypnea药物中毒瞳孔散大mydriasis颠茄类、酒精、氰化物瞳孔缩小myosis吗啡、巴比妥类、有机磷心动过缓bradycardia颅内高压、心脏病高血压hypertension高血压脑病、脑血管意外、尿毒症低血压hypotension休克皮肤粘膜改变mucocutaneouschanges严重感染、CO脑膜刺激征meningealirritation脑膜炎

蛛网膜下腔出血12

中年以上，有高血压病史，活动时发病，突感头痛、呕吐、昏迷、鼾声呼吸，偏瘫。头颅MR脑出血突感剧烈头痛，呕吐，即之昏迷，颈有抵抗，克尼格氏征阳性腰穿，头颅MR、脑血管造影蛛网膜下腔出血既往有心脏病史，特别是风心病心房纤颤着，突然抽搐、偏瘫、昏迷头颅MR

心电图脑栓塞昏迷不醒，有似深睡状态，四肢松软、瞳孔缩小

深入了解病人有无心理障碍，寻找药瓶，遗书.安眠药中毒急性起病，高热、剧烈头痛、呕吐、昏迷、颈项强直血常规，脑脊液检查化脓性脑膜炎急性起病的昏迷13

冬季发病，有一氧化碳中毒的可能环境，晨起被发现，昏迷、口唇成樱桃红色，面色潮红血清碳氧血红蛋白测定一氧化碳中毒用胰岛素治疗的糖尿病人，在饮食不当、胰岛素用量过大，出现心悸、出汗、无力、面色苍白、血压下降尿常规、血糖测定低血糖昏迷中年以上，有动脉硬化史，安静状态下发病，现有肢体活动不利，逐渐瘫痪或有一过性黑蒙，恶心、呕吐、昏迷头颅MR脑血栓形成青年、儿童，有结核病史，发热、头痛、恶心、呕吐、逐渐昏迷、颈项强直，克尼格氏征阳性胸片、脑脊液检查结核性脑膜炎糖尿病病史，饮食控制不当，饮酒、感染后出现恶心、呕吐、呼吸深大，呼气有烂苹果味血糖、酮体测定，尿糖、尿酮体，血气分析糖尿病昏迷亚急性起病的昏迷14

有慢性肾炎或高血压病史，食欲减退，恶心、呕吐