Sleep and its disturbances.... unconsciousness................ description

1. SLEEP & ITS DISTURBANCES,
UNCONSCIOUSNESS
PRESENTED BY
RITIKA RANA
MSC NSG
NIEROSCIENCES

3. INTRODUCTION:
 One third of human life is spent sleeping.
 Study performed at University of Pennsylvania School of Medicine
demonstrated that cognitive functions decline with fewer than eight
hours of sleep.
 Sleep has long assumed to be have restorative function and recently
people believed sleep to be a passive state of decreased stimulation.

4. DEFINITION:
 Sleep can be defined as complex rhythmic state involving a
progression of repeated cycles, each representing different phases of
body and brain activity, crucial for physical, mental, emotional well-
being. (Buysee, 2014).
 Sleep is naturally occurring altered state of consciousness characterized
by decreases in awareness and responsiveness to stimuli.

6. PHYSIOLOGY OF SLEEP:
 Sleep cycle is controlled by systems of brainstem. Bulbar synchronizing
region (BSR) and reticular activating system (RAS) are two major
systems of brain responsible for control of sleep cycle.
 Reticular activating system extends upward via pons, medulla, midbrain
into hypothalamus.
 It’s responsible for cortical activities related to state of alertness as well as
reflex and voluntary movements. It’s consisted of numerous nerve cells
and fibres.

7. CONT…..
 These relay impulses into cerebral cortex and spinal cord. Bulbar
synchronizing region are socialised cells in medulla and pons. It’s also
works by controlling cyclic nature of sleep.
 During sleep, RAS receives fewer stimuli from cerebral cortex and
periphery sensory organs. As stimuli to RAS reduces and a person try
to fall asleep by closing eyes & assuming relaxed posture, BSR takes
over and cause sleep.

8. CONT…..
 Wakefulness occurs when RAS activates by stimulation from cerebral
cortex and from periphery organs.
 Neurotransmitter’s play essential role in sleep cycle i.e., acetylcholine,
norepinephrine with serotonin, dopamine, and histamine involves in
excitation, GABA for inhibition.

9. CIRCADIAN RHYTHM:
 Circadian is made up of two Latin words “circa”, “dies”. Circa means
“about” & “dies” is Latin word for “day”, circadian describes 24-hours
daily rhythms.
 Sleep awake cycle is closely linked with other circadian rhythm such as
body temperature, gastric acid secretion, hormone secretion.

10.  Sleep is one of complex biologic rhythm of body. Circadian
synchronization occurs when sleep wake cycle of a person follows
inner biologic cycle located in hypothalamus.
 When physiologic or psychologic rhythms are high or most active,
person is most awake and when rhythms are low, person is asleep.

12. PHYSIOLOGIC FUNCTION:
 Based on two approaches are: -
 Electro-physiologic approach.
 Neurotransmitter approach.

14. 1. ELECTRO-PHYSIOLOGIC APPROACH:
1)Polygraph recording of electro-physiologic changes in brain waves, eye
movements and muscles show five sleep stages:-
 First- four stages are classified as non-rapid eye movement (NREM) sleep and
other stage is called REM (Rapid Eye Movement) sleep.
A.Non-Rapid Eye Movement Sleep:
 STAGE 1: it’s transition stage between wakefulness & sleep that normally
lasts 1-7 minutes. Person relaxed with eyes closed and has fleeting thoughts.
Alpha waves, present in people awake with eyes closed, diminished. People
awakened during stage often say they have not been sleeping.

15.  STAGE2: (LIGHT SLEEP) is first stage of true sleep. In, it a person is
little more difficult to awaken. Fragments of dreams may be experienced,
eyes roll from side to side. EEG show sleep spindles-bursts of sharply
pointed waves that occur at 12-14 hz and last 1-2 second.
 STAGE3: is a period of moderate sleep. Body temperature and blood
pressure decreases. It’s difficult to awaken person, EEG shows mixture of
sleep spindles and larger, lower- frequency waves. This stage occurs about
20 minutes after falling asleep.

16.  STAGE4: Slow wave sleep is deepest level of sleep. Slow, large-
amplitude delta waves dominate EEG. Although brain metabolism
decreases significantly during slow-wave sleep and body temperature
drops slightly, most reflexes are intact and muscle tone is decreased
only slightly. When sleepwalking occurs in this.
 Person goes from stage 1 to 4 of NREM sleep less than an hour.
During a typical 7–8-hour sleep there are 3-5 episodes of REM sleep
during which eye move rapidly back and forth under closed eyelids

17. B) RAPID EYE MOVEMENT:
REM sleep closely resembles wakefulness except for very low
muscle tone, indicated by reduction in amplitude of Electro muscle
gram.
Blood pressure and pulse rate show wide variations and may
fluctuate rapidly.
Respirations are irregular and oxygen consumption increases.
Vaginal secretions increase in women and erection may occur in
men.

18. 2. NEUROTRANSMITTERS:
 Sleep is an active process involving RAS and a dynamic interaction of
neurotransmitters.
 Communication between neurons in RAS primarily involves release of
specific neurotransmitters from axon terminals.
 Serotonin is major neurotransmitter associated with sleep. It decreases
RAS by inducing and sustaining sleep.
 Acetylcholine and nor-epinephrine are required for REM sleep cycle.

19. SLEEP CYCLE:

21. FACTORS AFFECTING SLEEP:
1. Physical activity.
2. Psychological stress.
3. Motivation.
4. Diet.
5. Alcohol intake.

22. CONT…..
CAFFEINE CONTAINING BEVERAGES.
SMOKING.
ENVIRONMENTAL FACTORS.
LIFESTYLE.
ILLNESS.

23. SLEEP DISTURBANCES
A.MAJOR DIAGNOSTIC TESTS:
1. DYSSOMNIAS:
i. Intrinsic sleep disorders.
ii. External sleep disorders.
iii. Circadian rhythm sleep disorder.
2. PARASOMNIAS:
i. Arousal disorder.
ii. Sleep wake transition
disorder.
iii. Parasomnias associated with
REM sleep.
iv. Other parasomnias.

24. CONT……
3. MEDICAL OR PSYHIATRIC DISORDER:
Associated with :
i. Mental.
ii. Neurological.
iii. Medical.
4. PROPOSED SLEEP DISORDER.

25. B. COMMON SLEEP DISORDER:
PRIMARY SLEEP DISORDERS:
Insomnia.
Hypersomnia.
Narcolepsy.
Sleep apnoea.
Parasomnias.
Sleep deprivation.
Early morning awakening .

26. SLEEP ASSESSMENT
Questionaries.
Sleep diary.
Nocturnal polysomnography.
Multiple sleep latency test.

29. SLEEP MANAGEMENT
 Preparing restful environment.
 Promoting bedtime rituals.
 Offering appropriate bedtime snacks and beverages.
 Promoting relaxation.
 Promoting comfort.
 Respecting normal sleep wake patterns.
 Using medications to produce sleep.
 Teaching about rest and sleep.

31. DEFINITION:
Unconsciousness is a stage of depressed cerebral function
which causes impairment in response to sensory stimuli
and abnormal loss of awareness of self and surroundings
to uncertain period of time.

32. CAUSES & RISK FACTORS
1. Intracranial causes:
Head injury.
Subarachnoid haemorrhage.
Cerebral infarction.
Intracranial tumour.
CNS infection.
Epilepsy/seizures.

33. 2. Extracranial causes:
Metabolic causes: hepatic failure, hypoglycemia/hyperglycemia.
Endocrine causes: hypopituitarism/hyperpituitarism.
Respiratory insufficiency: hypoventilation, anaemia, hypoxia,
hypercapnia.
Decreased cardiac output: MI, blood loss.
Psychogenic causes: hysteria.
Drug abuse: sedatives, hypnotics, anticonvulsants.
Toxins: alcohol, carbon monoxide.

34. PATHOPHYSIOLOGY
 BRAIN TISSUE DAMAGE
 INFLAMMATION
 EDEMA
 INTRACRANIAL PRESSURE
 DIFFUSION OF BRAIN TISSUES
 DISTURBANCES OF RAS UNCONSCIOUSNESS
UNCONSCIOUSNESS

36. CLINICAL MANIFESTATIONS
Body system Symptoms
Respiratory system Stridor, `progressive cyanosis, decreased respiratory
rate, decreased depth.
Cardiovascular
system
Bradycardia, hypotension, decreased cardiac output,
ventricular tachycardia
Neurological
system
Cranial nerve palsies, lethargy, absent doll’s eye reflex.
Gastrointestinal
system
Due to disruption of vagus nerve, abdominal
distension, constipation, ascites.
Urinary system Urinary incontinence, oliguria, UTI.

37. DIAGNOSTIC ASSESSMENT

38. CONT….
 CT-scan done to visualize internal structure of patient body.
 MRI reveals whether cause of coma is structural. Tumours or areas of
bleeding will be evident on scan.
 Lumbar puncture to diagnose about infection or bleeding cause of
coma. If CSF is bloody then patient has infection or bleeding into
ventricles or subarachnoid space.
 EEG to determine whether patient is comatose because of continuous
seizure.

39. MANAGEMENT:

48. 2. SYMPTOMMATIC TREATMENT:
Wernicke’s encephalopathy: Thiamine100 mg IV as an
initial dose followed by 50 to 100 mg/day IM or IV until
the patient is on a regular, balanced, diet.
Opioid Drug overdose: Naloxone 0.4 to 2 mg/dose
IV/IM/subcutaneously. May repeat every 2 to 3 minutes as
needed.

49. CONT….
Seizures: antiepileptic drug such as carbamazepine, sodium valproate
Infection: antibiotics drugs such as amoxycillin clavulanic acid.
Poison ingestion: gastric lavage
Fever: antipyretics, cold sponge
Pain: analgesics such as tramadol given.

50. 3. SURGICAL MANAGEMENT:
 Hematomas – Surgical evacuation of haemorrhage, tumour, cerebral
abscess.
 Surgical decompression/ Partial or total resection.
 Cerebral aneurysm - surgically clipping or endovascular coiling

51. COMPLICATIONS
 Hypoglycaemia.
 Failure of multiple organs.
 Fluid electrolyte imbalance.
 Pneumonia or other life-threatening conditions.
 Pressure sores.
 Deep vein thrombosis/ pulmonary embolism.
 Microbial keratitis is severe complication of corneal exposure in
unconscious patient.