altered level of consciousness ppt

Consciousness defined as being awake and aware of both one’s self and one’s surroundings, OR it is the human awareness of both internal and external stimuli - PowerPoint PPT Presentation We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. For example, caffeine is a stimulant, which means that it raises your levels of brain activity. 1,2 In young children, ALOC may manifest as fussiness or irritability. like an on/off In formulating a clinical judgement in such cases it is important to recognize that all existing indicators are surrogate markers for overwhelming neuronal death and disconnection within the cerebrum. it is a state of awareness, Altered States of Consciousness - . hypnosis . Dr. Bandar Al Jafen , MD Consultant Neurologist. Any disturbance in level of consciousness, either increased vigilance or decreased wakefulness, would … https://www.slideshare.net/sandraeweregboneme/level-of-consciousness-gcs A manifestation of altered consciousness implies an underlying brain dysfunction. Consciousness has two major components: content and arousal. a. AVPU. • Requires quick action to avoid irreversible damage • Wide array of possible diagnoses • ALOC is a symptom of another problem, not a diagnosis itself, Causes • A – Alcohol, Abuse (physical or substance) • E – Encephalopathy, Electrolytes • I – Insulin( hypoglycemia) • O – Overdose, Oxygen deficiency • U - Uremia • T – Trauma, Temperature abnormality, Tumor • I - Infection • P – Poisoning, Psychiatric, Psychogenic • S – Shock, Stroke, Seizures, Shunt Helpful mnemonic is AEIOU TIPS, Electrolytes • ALOC may be caused by: • Abnormality in any cation (Na, Ca, Mg, Phosphorus) • Metabolic acidosis or alkalosis • Hypoglycemia – most common • Hyperglycemia – especially new onset diabetes have ALOC due to hyperosmolarity • DKA can lead to cerebral edema. Sex: The Altered State of Consciousness - . Do a detailed physical exam. The term altered level of consciousness (ALOC) can be used to describe a spectrum of disorders that includes clouding of consciousness, confusion, lethargy, obtundation, stupor, or coma. sit back and relax…… now! Definitions. Definitions. ALOC can be caused by a head injury, medicines, alcohol or drugs, dehydration, or some diseases, such as diabetes. However, more frequently, patients exhibit altered levels of consciousness plus cognition: for example, with delirium, a relatively common and sometimes fatal cause of AMS. MRI showing bilateral paramedian thalamic infarction. Etiologies • Altered Level of Consciousness (ALOC): • One of the most difficult diagnostic and management problems. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. • Then treat underlying cause. Dry sobs, coupled with severe, profound shock. Altered Level of Consciousness. what the??????. At present, no measurements reliably allow an assessment of whether the underlying remaining brain structures in such patients may allow recovery of consciousness and higher level cognitive functions. Feature 3: Altered Level Of Consciousness Present If The Current Rass PPT. relaxing time is, EXAMINATION OF A PATIENT WITH HEPATIC ENCEPHALOPATHY/ALTERED CONSCIOUSNESS LEVEL - . Both represent some level of decreased consciousness but are more subjective descriptors than true objective findings. See our User Agreement and Privacy Policy. The following is a 30 slide PPT which introduces and discusses Altered States of Consciousness when teaching the Consciousness Unit in Psychology. techniques. Altered Level of Consciousness . sleep is: a state of altered consciousness, Altered States of Consciousness - . Polycythemia. People who are obtunded …  Persistent vegetative state is a condition in which the patient is described as wakeful but devoid of conscious content, without cognitive or affective mental function. Now customize the name of a clipboard to store your clips. Criterion 4 is altered level of consciousness, which is positive when a patient is clearly drowsy or sleepy. Presentation Summary : Consciousness: our level of awareness about ourselves and the environment.. most people, Altered States of Consciousness - . The Glasgow Coma Scale • The Glasgow Coma Scale or GCSis a neurologicalscale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. important vocabulary. With so many variables, it is not surprising that administration of an ideal dose to one patient can have a very different effect on an apparently similar patient. We spend most our lives in WAKING CONSCIOUSNESS (a normal state of clear, organized alertness.) Headache. Identification of patients in the first category—those with overwhelming structural brain injury—can frequently be done by inspection and clinical judgment (e.g., a patient with complete infarction of the dominant hemisphere and central herniation but not quite meeting brain death criteria). The same can be said about terms such as lethargy or obtundation. Management of Altered Mental Status in the Pediatric ED, No public clipboards found for this slide, Postgraduate Medical Institute of Hayatabad Medical Complex Peshawar. History of heart disease. GCS • Severe, with GCS ≤ 8 • Moderate, GCS 9 - 12 • Minor, GCS ≥ 13. Estimation of the likelihood of further functional recovery and the ultimate functional level of recovery in patients who lack negative predictors presents significant uncertainty. Treatment • Intermediate • D. If the patient is in respiratory arrest, perform advanced airway management. • Obtunded: More depressed level of consciousness and can not be fully aroused. These examinations need to be carried out by someone experienced in disorders of consciousness, although the views of other healthcare professionals and family members should also be taken into consideration. "Brain function in coma, vegetative state, and related disorders". (believing their altered sensory perceptions are real) • * altered level of consciousness Fluctuates throughout day • Usually oriented to person • Frequently disoriented to time and place • Decreased awareness of environment or situation May focus on irrelevant stimuli such as color of … Looks like you’ve clipped this slide to already. sleep and dreams. Loss of consciousness. The level of consciousness has been described as the degree of arousal and awareness. The syndrome of Akinetic Mutism includes patients who fulfil the criteria for MCS and patients who can functionally communicate when formally assessed yet demonstrate a severe reduction in spontaneous behaviour or extremely slowed interactive responses. substance abuse: pattern of use that diminishes one's ability to fulfill, Bilateral enlarged and unreactive pupils indicate massive, Oculovestibular reflex – elevate head of bed 30 degrees, Decorticate posturing, with elbows, wrists and fingers, Decerebrate posturing – rigid extension of arms and legs. It is the third group of patients who provide a significant challenge to the neurosurgical and neurological consultant. (1) A: Alert and oriented. A mildly depressed level of consciousness or alertness may be classed as lethargy; someone in this state can be aroused with little difficulty. Seeing flashing lights characteristics of altered states of consciousness. • Altered Consciousness covers a spectrum of states: • Consciousness • Lethargy • Stupor or Obtunded • Coma. highly suggestible no use of critical thinking changes in, Altered states of consciousness - Ted d. williams, pharmd pgy1 resident syracuse vamc 2010. altered states of, Altered States of Consciousness : Hypnosis - . Encouraged and interpreted by many different  The level of responsiveness and consciousness is the most important indicator of the patient’s condition. • F. Perform capillary blood glucose determination. Treatment • I. If you continue browsing the site, you agree to the use of cookies on this website. ALOC Clinical Features • 4 pathophysiologic variables are helpful • Respiratory pattern • Pupillary light reflexes • Spontaneous eye movements • Motor responses, Respiratory Pattern • Ventilation is governed by lower pons and medulla • Modulated by forebrain cortical centers • Patterns from rostrocaudal involvement • Cheyne Stokes respirations • Hyperpnea( deep and fast) alternating with apnea, Central neurogenic hyperventilation • Regular and rapid respirations • Normal PaO2 and low PaCO2 • Midbrain • Brain’s attempt to reduce ICP • Apneustic breathing • Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release • Signifies damage to Pons/medulla, Pupillary Reflex • Pupillary pathways near ARAS • Pupillary pathways resistant to metabolic insult • Single most important physical finding to distinguish structural vs metabolic disease, Bilateral enlarged and unreactive pupils indicate massive CNS dysfunction ( anoxia, barbiturate sever hypothermia and anticholinergics poisoning) . Additional Info: Began w/ German doctor Franz Mesmer in the late 1700’s. Altered or abnormal levels of consciousness describe states in which a person either has decreased cognitive function or cannot be easily aroused. The Lancet Neurology 3 (9): 537–546, In these studies, VS patients showed a reproducible reduction in resting metabolism to typically 30% to 50% of normal metabolic rates across cerebral structures. Through such projections, the SCN can modulate circadian rhythms in brain arousal to promote sleep. 2  Most medical conditions affect the brain and impair consciousness when they become serious or life-threatening, and an altered state of consciousness usually signals a serious medical problem. Pediatric Advanced Life Support. Altered State of Consciousness (def)…when distinct changes occur in the quality Feeling like you have "lost time" Memory loss (amnesia) of events before the injury or immediately after. Performing a physical exam is often the key to ruling in — or out … Establish an airway, maintain as indicated, suction as needed; assist ventilations as indicated. Level of consciousness should also be assessed upon initial contact with your patient and continuously monitored for changes throughout your contact with the patient. You can change your ad preferences anytime. Definitions • Lethargy: mild depression in level of consciousness and can be aroused with little difficulty. • E. Secure IV access. section 1: sleep and dreams. ALTERED STATES OF CONSCIOUSNESS CHAPTER 7 Consciousness (def)….all sensations, perceptions, memories and feelings you are aware of at any time. Altered Level of Consciousness. why do people sleep?. Altered Levels of Consciousness in the Disease of Schizophrenia highest altered level of consciousness occurs when the schizophrenic weeps but no tears come, and there is no real "feeling" capacity at all. Neurotransmitter and neuropeptide systems involved in brain arousal and therefore in cognitive and affective function include the monoaminergic neurotransmitters histamine (His) from the tuberomammillary nucleus (TMN), norepinephrine (NE) from the locus coeruleus (LC), serotonin (5-HT) from the midbrain raphe nuclei, dopamine (DA) from the ventral tegmental area (VTA), and substantia nigra (not shown); the cholinergic neurotransmitter acetylcholine (ACh) from the basal forebrain (BF) and the pedunculopontine (PPT), and laterodorsal tegmental nuclei (LDT); the peptide orexin (ORX), also referred to as hypocretin, from the lateral hypothalamus (LH); the excitatory amino acids glutamate (GLUT) and aspartate; vasopressin (VP), and vasoactive intestinal polypeptide (VIP) from the suprachiasmatic nuclei (SCN). • Ascending reticular activating system is a group of neural connections that receive sensory input and projects to cerebral cortex through the midbrain and thalamus from the reticular formation. TO BE AWARE. today’s goal: discuss theories of hypnosis, noting the, Altered States of Consciousness Sleep, Dreams, Hypnosis, and Drugs - . NOT. Slide 10 Altered LOC and Associated … Presentation Summary : Feature 3: Altered level of consciousness Present if the current RASS score is anything other than alert and calm (zero) Feature 3 is present if RASS is not Variations in Consciousness Levels of awareness Consciousness is not all-or-none Awake Sleep Anesthesia Coma Persistent Vegetative State Death Definitions of Death As little as 50 years ago, people were considered “dead” when their heartbeat & breathing stopped. This page includes the following topics and synonyms: Altered Level of Consciousness, Decreased Level of Consciousness, ALOC, Altered Mental Status, Altered Mental State, Altered State of Consciousness, Depressed Level of Consciousness, DONT Mnemonic. Chapter 66 Management of Patients With Neurologic Dysfunction Altered Level of Consciousness (LOC) Level of responsiveness and An altered level of consciousness is any measure of arousal other than normal. A disorder of consciousness will only be confirmed after extensive testing to determine the person's level of wakefulness and awareness. what is consciousness?. Altered Level of Consciousness What is altered level of consciousness? Hypnosis. The patient’s LOC is reported as A, V, P, or U. Treatment • Basic • A. Get powerful tools for managing your contents. Laureys S, Owen AM, Schiff ND (2004). If you continue browsing the site, you agree to the use of cookies on this website. Altered Consciousness This PPT presents the main ideas, concepts, and terms in a simple and straightforward manner using real world examples, application activities, you tube Dr. Bandar Al Jafen , MD Consultant Neurologist. Altered Level of Consciousness Pathophysiology: Not a disorder itself Results from multiple pathophysiologic phenomena Name three categories of cause What is the primary assessment tool? ( slow response and sleepness) • Stuporous: Can not be aroused from a sleep like state. Acetaminophen Overdose in Pediatric Populations. outline of, Characteristics of Altered States of Consciousness - . The terms, “Altered mental status” and “altered level of consciousness” (ALOC) are common acronyms, but are vague nondescript terms. cogs 175, june 5 th 2006 part i: cody frew, rachel jaffe, rajiv rao part ii: Flow An Altered State of Consciousness? Trauma • Epidural Hematoma • Lens shaped • Caused by arterial rupture • Skull fracture present in 85% of cases, Subdural hematoma • Crescent shaped • Caused by tearing of bridging veins through dura and arachnoid • Skull fracture present in 30% of cases • Retinal Hemorrhage in 75% of cases, Cerebral Contusion • Can lead to increased ICP, Meningitis • Bacterial • Most common infection severe enough to cause profound ALOC • Non-bacterial • Slower onset of symptoms, Infection • Brain Abscess • Chronic sinusitis, chronic otitis, dental infection, endocarditis or uncorrected cyanotic congenital heart disease can increase risk, Encephalitis • Encephalitis – inflammation of the brain parenchyma usually due to viral infection • HSV – most common devastating cause • Death or permanent neurologic damage in 70% of cases • Affects temporal lobes causing seizures, parenchymal swelling and uncal herniation, Stroke • Hemorrhagic is usually due to aneurysm • Severe headache • AVM or cavernous hemangioma • Low flow and less acute symptoms, Stroke • Thrombosis or Embolic Stroke • Occlusion of anterior, middle or posterior cerebral artery will NOT cause coma • Infarcts eventually lead to increased ICP • Cerebellar infarcts rarely have coma • Basilar Artery infarcts cause rapid coma due to brainstem damage, Hypoxia • Neurons extremely sensitive to hypoxia and cease function within seconds of hypoxia • Permanent CNS dysfunction can occur within 4-5 minutes of total anoxia at body temperature • Hypercarbia can also cause neurologic depression and coma, Temperature • Hypothermia • Each drop by 1 degree celcius causes a 6% drop in cerebral blood flow • Hyperthermia • Headache, vomiting, seizure, obtundation, or coma result especially above 41 degrees C, Investigations • CT brain • MRI brain • Glucose • Electrolytes • LFTs • BUN • PT, PTT • Calcium • Serum • Ammonia • Osmolality • Calcium • Ketones • Alcohol • Drug concentrations • ABGs. • G. If patient’s blood glucose level is <80 mg/dl, administer dextrose 50% 25 gm • H. Unless patient responded to dextrose administration, contact medical direction for an order to administer 2 mg of naloxone intravenously. Nausea and vomiting. PG Neurosurgery hypnotist. ( only respond by grimacing or drawing away from painful stimuli) • Coma: More depressed level of consciousness and unable to make any purposeful response. Consciousness: Our Level Of Awareness About Ourselves And The Environment.. Clipping is a handy way to collect important slides you want to go back to later. Literally an altered state deviating from ones normal mental state. The following is a 30 slide PPT which introduces and discusses Altered States of Consciousness when teaching the Consciousness Unit in Psychology. The AVPU scale is a rapid method of assessing LOC. (B) The master circadian clock located in the SCN has modulatory input to many of the ascending arousal pathways, some through direct projections from the SCN (not labeled, see text) and many through indirect projections relayed by the dorsomedial hypothalamus (DMH). This psychological definition implies that consciousness is . This PPT. consciousness: a state of awareness, including a, Altered States of Consciousness - . Conscious patients are awake and responsive to their surroundings (Marcovitch, 2005). • Drugs also affect pupils • Opiates – pinpoint pupils • Anticholinergics – large pupils, Eye Movements • In light stage of coma, roving side-to-side movements occur • Persistent deviation to one side may indicate focal seizure activity • Structural brainstem lesions abolish conjugate eye movements • Oculocephalic reflex (“doll’s eyes”) – hold eyelids open and rotate head from side to side • Normal or positive – conjugate deviation of eyes away from direction of head movement • Contraindicated in c-spine injury, Oculovestibular reflex – elevate head of bed 30 degrees and inject 10-50ml of ice water into ear canal • Normal response is nystagmus with slow phase towards irrigated ear and fast beats away • Unconscious pt with intact brainstem eyes move towards stimulus and remain tonically deviated for a minute and slowly return to midline • Contraindicated if tympanic membrane not intact, Motor Responses • Assess muscle strength, tone and deep tendon reflexes for normality and symmetry • Assess if pt can localize motor responses to determine level of brain lesion, Decorticate posturing, with elbows, wrists and fingers flexed, and legs extended and rotated inward • Lesion in cortex or subcortical white matter, Decerebrate posturing – rigid extension of arms and legs • Lesion at brainstem, usually pons. © 2021 SlideServe | Powered By DigitalOfficePro, - - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -. brought about via . vocabulary. ▲ If IV access cannot be secured and the patient's blood glucose level is <80 mg/dl, administer 1 mg glucagon IM. These substances can help to maintain or decrease consciousness. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Seizure • All seizures except petit mal are followed by a post-ictal state • Measure drug levels for patients on anticonvulsants. Title: Altered States of Consciousness 1 Altered States of Consciousness. Unfortunately, there is no classic presentation for a patient with AMS. conditions where the state of awareness or wakefulness is disturbed The residual effects of a drug (after administration has ceased) are influenced by a number of factors, as outlined in Table 1. describe the research related to sleep and dreaming define, Altered States of Consciousness - “his was a great sin who first invented consciousness. definitions of, Altered States of Consciousness - . These patients will have sufficient evidence from their clinical history, structural injury to critical brain structures evident on imaging, or electrophysiologic markers of diffuse neuronal dysfunction to raise concern of futility, but they do not demonstrate known clinical or laboratory indicators that predict permanence of their condition. Chapter 7: Altered States of Consciousness - . The uncertainty of outcome for an individual patient in coma, VS, or MCS will vary considerably, depending on the details of clinical findings obtained from bedside examinations, time from the initial injury, and the specific cause of the injury. • Unilateral fixed dilated pupil indicate ipsilateral expanding mass and possible herniation. See our Privacy Policy and User Agreement for details. Prior to the mid-1990s, there was a lack of operational definitions available to clinicians and researchers to guide the differential diagnosis among disorders of consciousness. chapter 7. hypnosis. Consciousness is defined as the state of being aware of physical events or mental concepts. used by a . Changes in the level of consciousness. Dr Mukhtar literally an “altered, Altered States of Consciousness - Sleep and dreams. • J. If psychogenic processes are excluded, observed alteration of consciousness in all settings implies one of the following possibilities: (1) diffuse functional impairment of both hemispheres as a result of direct injury and toxic/metabolic alterations associated, for example, with cardiopulmonary dysfunction, infection, poisoning, or a variety of other processes producing bilateral cerebral dysfunction, such as antibody-mediated alteration of neurons or axons, and (2) selective impairment of midline and paramedian upper brainstem and basal forebrain regions containing nuclei associated with ascending arousal input to the anterior forebrain, often damaged in combination with central thalamic nuclei (or isolated to the central thalamus if the lesions are bilateral and relatively large in rostrocaudal extent). 2. This podcast presents a basic overview of the Pediatric Advanced Life Support protocol from the 2015 American Heart Association guidelines. you are looking around the room and your awareness is, Altered States of Consciousness - . major differential, Altered States of Consciousness - . Alternatively, patients in delirium may also be restless or agitated. (A) Brain arousal for neurocognitive and neuro-affective function is promoted by ascending brain stem, forebrain and hypothalamic projections to the cortex and midbrain. presented by: liana ma casey armstrong jessica shindo. Impaired vision. Create stunning presentation online in just 3 steps. consciousness sleep hypnosis drugs. The first level of behavioural recovery beyond VS is operationally defined as MCS. mental experiences that transcend ordinary experiences . - . Mental experiences that transcend ordinary experiences. Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment. Consciousness defined as being awake and aware of both one’s self and one’s surroundings, OR it is the human awareness of both internal and external stimuli, Altered Level of Consciousness Dr. Bandar Al Jafen, MD Consultant Neurologist, Definitions • Consciousness defined as being awake and aware of both one’s self and one’s surroundings, OR it is the human awareness of both internal and external stimuli • Level of consciousness : is a measurement of a person’s arousability and responsiveness to stimuli from the environment. The content of consciousness represents the sum of all functions mediated at a cerebral cortical level, including both cognitive and affective responses, The arousal level appears to influence all neuropsychological functions in humans and animals and absence of an aroused state precludes behaviour. used for pain control, anesthetic, reduce anxiety, overcome fears, quit smoking, • C. Transport the patient in the coma/recovery position (if trauma is suspected, transport supine with cervical collar and backboard). approach to the patient with altered consciousness, how to decide the prognosis and how to map out the outcome. in 1959, new york disc jockey peter tripp stayed awake for 200, Consciousness & Altered States of Consciousness - . https://www.slideshare.net/kuzagar/altered-consciousness-36506883 Altered state of consciousness in which people respond to suggestions and behave as if in a trance. (C) The SCN has modulatory input to the sleep systems via relay projections to the DMH, onto the sleep promoting VLPO as well as midbrain and brain stem arousal systems. • Pinpoint pupils indicate pontine hemorrhage, Opiates, organophosphate poisoning. guided meditation. dr. amin ul haq. View PPT_Chapter66.pptx from NURS 221 at Dalton State College. For example, coma associated with loss of motor response and pupil and corneal reflexes initially and enduring over the first 48 to 72 hours is invariably associated with outcomes no better than permanent VS after cardiac arrest once potential confounding variables are excluded. chapter 7. objectives. Autopsy studies of patients with clinical histories consistent with MCS demonstrate reduced overall levels of cerebral cell death and, in some MCS patients, no evidence of significant thalamic cell loss or severe diffuse axonal injury—a pattern never observed in VS patients. No emotion is registered in the psyche on a feeling level at all. ▲ Administer thiamine 100 mg IV if dextrose is to be administered. Coma is an inherently grave illness associated with very high mortality; studies indicate that 40% to 50% of patients in a coma after brain trauma and 54% to 88% of patients comatose after cardiac arrest die, The prognosis of VS patients similarly depends on the mechanism that underlies the brain injury, Prognosis in MCS is the least well characterized because the diagnostic category is relatively new and the available studies suggest that significant further recovery may occur in some patients after 1 year in MCS, Several recent neuroimaging studies of VS and MCS patients suggest that functional imaging tools may become part of the comprehensive assessment of neurological disorders of consciousness, 1. May induce emotions like fear/anxiety, well-being, connection to supernatural entities. Prospective studies of large numbers of patients in coma have codified a number of strong clinical predictors of death or outcomes limited to permanent VS after the two most common causes: cardiac arrest and severe traumatic brain injury. Pathophysiology • Reticular formation is known to play a role in alertness, wakefulness and arousal. Valvular heart disease, dysrhythmias, heart failure, bacterial endocarditis. consciousnessour awareness of ourselves and our environmentswe, Altered States of Consciousness - Dependence. The “AMS” label may be applied to a patient who is postictal or perhaps a pati… Altered level of consciousness (drowsy, hard to arouse, or similar changes) Confusion, feeling spacey, or not thinking straight. https://www.slideserve.com/temira/altered-level-of-consciousness Altered level of consciousness - Confusion, delirium, somnolence, stupor, syncope, coma Abnormal movements - seizure, dystonia, abnormal posturing Neurological deficits: impaired cognition, memory, sensory or autonomic function • Comatose patients may have non-convulsive seizures needing an EEG to diagnose. HMC, Peshawar. Through such projections, the SCN can modulate circadian rhythms in brain arousal to promote wakefulness. is . Altered electrolytes Irritability, change in level of consciousness Metabolic acidosis (ketosis) Acidotic breathing, nausea, vomiting, abdominal pain, altered level of consciousness 7 Managing DKA Slide no 7. counsciousness rem sleep circadian rhythm insomnia sleep apnea. Akinetic Mutism is a classic finding after rupture of an anterior communicating artery aneurysm. Circulation o Subjective Data: History of stroke. Obtain blood specimen for glucose determination at the hospital if the receiving hospital desires it. • B. Administer high concentration oxygen. Changes in muscle tone (flaccid or spastic), paraliysis (hemiplegia), general weakness. Thus, it is most important to have a reasoned and systematic strategy to assess these patients. chapter 7. consciousness. let us lose it for a few, Altered States of Consciousness - . Altered level of consciousness (ALOC) means that you are not as awake, alert, or able to understand or react as you are normally. Approach to Patient Assessment

Novia De J Balvin Síndrome De Down, Coors Light Can Svg, Alara Name Pronunciation, Ode To Joy Cello Youtube, Know Your Worth Quotes For Him, What Was Rick's First Thought After His Accident, Nanowrimo Plot Ideas,