Approach to comatose child

Uncategorized 1 Minute

COMA

• Unawareness of self and environment • Preserved brain stem reflexes • 3months after Nontraumatic injury Vegetative state...Lethargy reduced wakefulness Obtundation blunted alertness , diminished awareness to environment Stupor Unresponsive but a...Diffuse bilateral hemispheric process Toxins and drugs • Alcohol, narcotics, benzodiazepines Metabolic • Diabetic ketoacid...1)Coma with focal signs 2) Coma without focal signs and without meningeal irritation 3) Coma without focal signs and with ...Int J Contemp Pediatr. 2015 May;2(2):77-84 • Rapid assessment of general state. • Non Specific interventions for all ill children. • Specific measures to rapidly cat...• Check Airway • Breathing • Circulation • Check pupil size, symmetry, and reaction to light APVU scale : •Alert •Responds to Voice •Responds to Pain •Unresponsive  Monitor : Heart rate, Respiration, Oxygen saturat... Infections : fever ,headache , vomiting , rash , seizures,irritable  Encephalopathy with preceding fever or minor illne... Vital signs  Head to toe examination bite marks for snake bite , regional lymphadenopathy , local signs if present  Level of consciousness  Pupils  Motor response  Brainstem function  Fundus  Signs of meningeal irritation  Herniat...• Shock • Sepsis • Trauma /NAI • Metabolic illness • Intracranial infection  Snake bite  Toxin exposure Always check blo...Basic investigations :  Blood glucose , complete blood count , blood biochemistry  Urine ketones / reducing substances ... Second line of investigations  Metabolic testing  MRI  EEG  In unexplained cases – thyroid antibodies / CNS vasculit... Immediate management : tilt head up 20 to 30 degrees.  Ensure adequate circulation –do not restrict fluids routinely. A... Systemic review of all studies - use osmotic agents to treat raised intracranial pressure in traumatic and non traumatic... Infants presenting with non specific symptoms or altered consciousness with seizures have may have inflicted head injury... Apnea has a positive predictive value of 93% and an Odds Ratio of 17.  Retinal Hemorrhages have a PPV of 71% with an Od... Rib fractures : 73% PPV and OR of 3.02, but wide confidence interval, so not so useful.  Seizures : PPV of 66% and OR o... Apnea probably reflects hypoxic ischemic injury as a consequence of iHI.  Final diagnosis must take into consideration ... Depends on the etiology, depth and duration of impaired consciousness  Prolonged coma after a hypoxic-ischemic insult c...Indian studies Non traumatic coma. Bansal A1, Singhi SC, Singhi PD, Khandelwal N, Ramesh S. Indian J Pediatr. 2005 Jun;72(6):467-73. Poor Prognostic Factors :  Younger age group  Lower GCS score on presentation  Absent brainstem reflexes  Worse motor ... Developmental disabilities  Learning and behavior problems  Visual or hearing deficit  Seizure disorder  Coma and other states of impaired consciousness represent a medical emergency.  Potential causes are numerous, and the ...Approach to comaApproach to comaApproach to comaApproach to comaApproach to comaApproach to comaApproach to comaApproach to coma

 

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Introduction  2 of 19  From the Greek koma, meaning "deep sleep"  It is an alteration of consciousness in which a p...Disorders of Consciousness  3 of 19  Lethargy: difficulty maintaining an aroused state, can be aroused with little d...Coma mimics  4 of 19  Complete paralysis: locked-in state, GBS, botulism  Akinetic-mutism: frontal lobe lesions, to...Etiology  5 of 19  Consciousness can be diminished or abolished by  Dysfunction within the brainstem  Impairment ...Etiologies-1  6 of 19  Infection  Meningitis  Encephalitis  Brain abscess  Trauma  Shaken baby syndrome  ...Etiologies-2  7 of 19  Epilepsy  Subclinical status epilepticus  Postictal states  Stroke  Arterial ischemic ...Evaluation   Vital signs and general and trauma examination  Neurologic examination and GCS  Screening laboratorie...Pupillary reflex  9 of 19 Size Possible interpretation Normal eye with two pupils equal in size and reactive to light...10 of 19 11 of 19 Pediatric GCS Sign Pediatric GCS Score Eye opening Spontaneous 4 To sound 3 To pain 2 None 1 Verbal respo...12 of 19 Management-1  13 of 19  ABCs:  Intubate if GCS ≤8 or respiratory failure  Stabilize cervical spine  Supplement ...Management-2  14 of 19  Infection:  Ceftriaxone 100 mg/kg (maximum single dose 2 grams) and Vancomycin  Acyclovi...Prognosis  15 of 19  Largely specific to the etiology  Mortality rates according to a study in England:  near-dro... 16 of 19 Coma Sequelae  Coma is transient, patients either recover, die or go into a more permanent state of impair...Persistent Vegetative State (PVS)  17 of 19  No evidence of awareness of self or environment and no ability to inter...

 

• A 5 year old child was brought with history of fever, progressive lethargy and posturing for 3 days . He had been vomiti...contents  Terminology -States of altered conciousness. Etiology Approach  Rapid assessment & Stabilisation.  History....• Consciousness is the state of awareness of self and environment. Impairment of consciousness states • Impairment of consciousness with activated mental state • Impairment of consciousness...Impairment of consciousness with activated mental state • Confusion: state of impaired ability to think and reason clearly...Impairment of consciousness with reduced mental state • Drowsiness • Obtundation arousal is present to stimuli • Stupor St...• Coma is a “state of deep, unarousable, sustained pathologic unconsciousness with the eyes closed that results from dysfu...• Increased neuronal excitability  Restless/Confusion Delirium Stupor Coma • Decreased neuronal excitability Lethargi...Etiologies of Impaired Consciousness and Coma 1.Infectious or Inflammatory A. Infectious • Bacterial meningitis • Viral en...Etiology –cont. 2. Structural A. Traumatic  Concussion  Cerebral contusion  Epidural hematoma or effusion  Intracerebr...Etiology –cont. 3.Metabolic, Nutritional, or Toxic A. Hypoxic-Ischemic Encephalopathy  Shock  Cardiac or pulmonary failu...Etiology -cont C. Nutritional  Thiamine deficiency  Niacin or nicotinic acid deficiency  Pyridoxine dependency  Folate...PATHOPHYSIOLOGY OF COMA • Consciousness has two dimensions – wakefulness and awareness. • Integral Consciousness requires ...ANATOMY AND PHYSIOLOGY - CONSCIOUSNESS Function Site Awake – RAS (Reticular Activating System) •Rostral brainstem (midbrai...Aetio-pathophysiological approach COMA Structural lesions Metabolic disorders  Usually focal  Diffuse and symmetric Supr...• Coma with focal signs  Intracranial hemorrhage  Stroke: arterial ischemic or sinovenous thrombosis  Tumors  Focal in...• Coma without focal signs and with meningeal irritation:  Meningitis  Encephalitis  Subarachnoid hemorrhage • Coma wit...Clues to etiology of coma in general examination Look for if present ,think of Pallor Cerebral malaria, intracranial bleed...Rapid neurogical assesment • The goal of neurologic examination are: To determine depth of coma. To localise the process...A.Level of conciousness • The level of conciousness must be recorded in the form of an objective scale. • The Glasgow coma...Glasgow coma scale ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) 1. Sponta...Significance of Glasgow coma scores: • Diagnosis of different grades of altered consciousness. • Coma is defined as: No ey...B. Size and reactivity of pupils Pupils Lesion/Dysfunction Pinpoint Pons, opiates, cholinergic intoxication Mid position –...C. Eye movements • Oculocephalic or Doll’s eye response: Shows Intact Brainstem. • Oculovestibular response: Lost in ponti...D. Motor response • Single best indicator of the depth and severity of coma 1. Spontaneous movements. 2. Tone and reflexes...Motor responses to noxious stimuli. A, Localization of pain as patient attempts to remove stimulus. B, Decorticate posturi...• Decorticate posturing with flexion of the upper extremities and extension of the lower extremities suggests involvement ...E. Respiratory pattern • Patient breathing pattern is also helpful in localising area of CNS dysfunction. They are : • Che...A.Cheyne-Stokes respiration-bilateral cerebral /diencephalon dysfunction ,preceding to transtentorial herniation B.Central...Herniation syndromes • Brain tissue deforms intracranially and moves from higher to low pressure when there is asymmetric,...• In transtentorial or central herniation, the diencephalon is displaced through the notch of the tentorium cerebelli into...Central vs uncal herniation Central uncal •Arousal •Breathing •Pupils •Oculocephalic responses •Motor signs •Impaired earl...Metabolic vs structural coma METABOLIC, TOXIC, INFECTIOUS CAUSES • Confusion or stupor precede motor signs • Pupillary rea...Investigations 1. neuroimaging: • CT scan:Any comatose child or infant in whom the neurological findings suggest a structu...Subdural Hematoma Acute epidural hematoma and midline shift Cerebral Abscess Cerebral edema Biochemical investigations investigations electroencephalography EEG findings Interpretation •High voltage slow waves •Slowing of background activity •Triphasic wav...

 

TREATMENT • Emergency measures (immediate life support) • Specific therapy SPECIFIC THERAPY • Acute febrile encephalopathy: In sick children with Acute febrile encephalopathy, empirical therapy wit...Specific therapy-Acute febrile encephalopathy: • Empiric antibiotic therapy: IV ceftriaxone+ amikacin • Acyclovir - in spo...prognosis • The prognosis for recovery from coma depends primarily on the cause, rather than on the depth of coma. • Coma ...appropriate long-term therapy • Early rehabilitation, by a team comprising doctors, teachers, physiotherapist, occupationa...Management approach-outline Thank you  Alert: Fully conscious  Lethargic: appear somnolent, but may be able to maintain arousal  Obtunded: requires touch or ...• Minimally Conscious State “a condition of severely altered consciousness in which the person demonstrates minimal but de...

• Vegetative State “condition of complete unawareness of the self and the environment, accompanied by sleep–wake cycles wi...Severe Disorders of Consciousness Condition Self- Awareness Pain and Suffering Sleep– Wake Cycles Motor Function Respirato...

 

 

 

 

 

 

 

 

 

 

 

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• Post infectious disorders:  ADEM  Hemorrhagic shock and encephalopathy syndrome • Post immunisation encephalopathy  W...The goals of coma therapy (a) Adhere to the principles of neuroresuscitation, the A, B, and Cs (b) Immediately identify si...Rapid assessment and stabilization • Establish and maintain airway: intubate if GCS<= 8 ,impaired airway reflexes, abnorma...• Identify signs of cerebral herniation or raised ICT: ( if GCS<8,abnormal pupil size and reaction, absent dolls eye movem...• If there are seizures: give IV lorazepam 0.1-0.2mg/kg , then phenytoin 20mg/kg loading. • Immobilisation of cervical spi...History ,physical examination and neurological assesment • History: age Infant Child Adolescent CNS infection (meningitis,...Approach: History • Onset : – Sudden onset: vascular catastrophy or a convulsion – Acute onset in normal child: ingestion ...Approach: History • Associated symptoms of CNS causes: – Fever – Infections – Headache, Vomiting, Diplopia – Increased ICP...Approach: History • Recurrent episodes: Epilepsy, Inborn errors of metabolism • H/o recent infectious diseases – eg. Mumps...Approach: History • H/o loose stools- HUS, Hypovolemia ,Ingestion of toxins/poisons, medications • H/o Immunocompromised s...Physical examination • Vital signs: – HR: Bradycardia (↑ ICT, myocardial injury due to hypoxia, sepsis), Tachycardia (Shoc...– Temp: Fever in Infections, Hyperpyrexia, Hypothalamic lesion or pontine hemorrhage, atropine poisoning, Hypothermia in S...• Any signs of trauma (Scalp laceration/swelling/fracture, ENT Bleeding) • Pallor - hypoxia, bleeding disorders • Icterus ...• CVS: Arrhythmias, Murmurs (Congenital heart disease, Infective endocarditis) • Chest: Signs of lung disease • P/A: Tende...

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