a patient in medical ICU presents with neurologucal symptoms-how to approach him?

10. Neuro muscular blockers in ICU renal 137+ 80-100 pipecuronium renal 100+ 90-120 doxacurium renal 240 80-120 tubocurarine hepatic renal 110-140 120-180 pancuronium renal 80-100 30-67 rocuronium hepatic renal 60-130 20-60 vecuronium renal 20 30-40 atracuronium renal 2 12-18 mivacurium hepatic - 60-120 12-17 rapacurium renal -t1/2 5-10min succinylcholine

11. Sedatives in ICU Cbf,icp 2-14 ketamine Cbf,icp,cpp 40-50 propofol Cbf, cpp, icp 10-19 haloperidol 48-144 phenobarbitone Cbf,icp,cpp 2-4 thiopental 10 fentanyl Cbf,icp 4-11 morphine 7-10 midazolam 3-7 lorazepam Icp, cbf, 50-120 diazepam

15. Abnormal pupillary responses in coma Metabolic encephalopathy, B/l thalamic, pontine lesions, hydrocephalus,narcotics,OP,barbiturates Midbrain damage or compression Seizure Thalamus, sympathetic efferents from posterior hypothalamus, tegmentum, descending to the cervical cord Bilateral small ,reactive b/l dilated and unreactive b/l dilation&reactive Unilateral miosis

16. Pupillary responses and coma Compression of ipsilateral III nerve -Fascicular lesion -Nuclear lesion -Extracranial defect T1-T2 to carotid bifurcation -Between hypothalamus and spinal cord -ICA vs cavernous sinus vs SOF vs orbit Unilateral, unreactive & enlarged -unilateral ptosis -bilateral ptosis Unilateral,small,reactive, ipsilateral ptosis -with face anhydrosis -anhydrosis entire side of body -without anhydrosis

17. Glasgow coma scale

19. Cerebral herniation :clinical syndromes Decrease consciousness, small & reactive pupils, normal eye movements. Fixed pupils, cheyne stroke respiration, opthalmoplegia, decorticate posturing Initial obstruction hydrocephalus, thalamus, hypothalamus displacement Supra tentorial diffuse brain edema, haemorrage, midline tumors Central herniation Dilated ipsilateral pupil with preserved or sluggish reaction to light. CnIII,ophthalmoplegia,ipsilateral hemipareis Ipsilateral III compression Hemispheric/lateral middle fossa Uncal herniation

20. Cerebral herniation clincal syndromes All brainstem reflexes are lost, flaccid paralysis, ataxic respiration, then ceasing Medulla-lower pons, cerebellar tonsils Infra tentorial lesions Foramen magnum herniation Decerebrate posturing, midposition pupils, sometimes irregular and loss of pupillary, oculocephalic and oculo vestibular reflexes Midbrain and upper pons Advanced stage of central herniation, upward infra tentorial lesions Midbrain compression