Approach to comates child

By hana (C2)
Moderator : dr. Abera (MD, pediatrician)
OUTLINES
• INTRODUCTION
• CAUSES OF COMA
• CLINICAL APPROACHES (HX&PE)
• INVESTIGATION
• MANAGEMENT
• PROGNOSIS
INTRODUCTION
• Coma is an alteration of consciousness in which a person appears to
be asleep, cannot be aroused, and shows no awareness of the
environment .
• Coma is therefore the most profound degree to which the two
components of consciousness, arousal and awareness, can be
diminished..
• represents an acute, life-threatening emergency, requiring prompt
intervention for preservation of life and brain function.
DEFINITIONS —
Consciousness has two dimensions :
a) Wakefulness/arousal or alertness
b) Awareness of self and surroundings(environment)
• Arousal depends on intact communication between the ascending
reticular activating system (ARAS) and its targets in the hypothalamus,
thalamus, and cerebral cortex.
• The ARAS is a loosely organized network of neurons within the
brainstem whose major function is to modulate arousal in response to
signals from the environment .
There is a spectrum of impaired consciousness between full arousal
and complete unresponsiveness.
• Alertness: The patient is awake and fully aware of normal external
and internal stimuli.
• Delirium – Delirium is a disturbance of consciousness with reduced
ability to focus, sustain, or shift attention
• Lethargy: The patient is not fully alert, Tends to drift to sleep when
not stimulated, When aroused has appropriate response.
• Obtundation:
Difficult to arouse. When aroused he is in a confusional state.
Usually constant stimulation is required to elicit even marginal
cooperation from the patient.
• Stupor: Respond only to persistent vigorous stimulation. When
aroused, is able only to groan or mumble.
• Coma – Coma, a state of "unarousable unresponsiveness," is the most
profound degree to which arousal and consciousness are impaired
• Persistent vegetative state – Persistent vegetative state (PVS)
describes patients who are completely unconscious but have
spontaneous eye opening during cyclical periods of arousal.
• Such patients often have reflexive vocalizations (sounds but not
words), facial expressions, and movements that can be misinterpreted
by hopeful observers as reflecting awareness of their internal or
external environment
• Brain death – Brain death criteria include coma, apnea, and absent
brainstem reflexes.
A diagnosis of brain death specifically implies no chance of recovery
and is synonymous with death in most countries.
• Locked-in-syndrome (LIS)
a state of quadriplegia & anarthria with preserved consciousness.
• Two requisites for the dx:
- retained alertness & cognitive abilities;
- paralysis of the limbs & oral str. such that the individual cannot signal
with the limbs/speak.
Causes
• Causes can be categorized as traumatic (including abusive head
trauma) and nontraumatic.
Common nontraumatic causes of coma include
• Infections (eg, meningitis, encephalitis, severe sepsis)
• Accidental and intentional poisonings and overdoses
• Metabolic disorders (eg, hypoglycemia, diabetic ketoacidosis, inborn
errors of metabolism)
• Seizures
• Intracranial hemorrhage (eg, due to vascular malformation) or mass
lesion (eg, tumor)
• Hypoxic-ischemic injury, which can result from any of the above
mechanisms or from cardiopulmonary arrest (eg, arrhythmia,
underlying congenital heart disease, foreign body aspiration, acute
respiratory failure)
• Drowning
• Traumatic and nontraumatic causes of coma have roughly equal
annual incidences of approximately 30 per 100,000 children each.
• With the exception of abusive head trauma, nontraumatic causes are
more frequent in infancy and early childhood.
• In most series, infection is the leading cause, composing 30 to 60
percent of cases
EVALUATION 
•  Coma is a medical emergency whose evaluation requires a rapid,
comprehensive, and systematic approach.
• Early identification of the underlying cause of coma can be crucial for
patient management and prognosis
History
• The history of symptoms leading up to coma may also provide clues.
• Coma of abrupt and unexplained onset suggests intracranial
hemorrhage, seizure, trauma, or intoxication.
• A gradual deterioration of mental status suggests an infectious
process, metabolic abnormality, or slowly expanding intracranial mass
lesion.
• A history of preceding headache, double vision, or nausea suggests
increased intracranial pressure (ICP).
• Inborn errors of metabolism may also present with slowly evolving
coma or recurrent episodic coma
• Toxic ingestions in young children are often unwitnessed, and parents
should be questioned regarding the possibility of available substances
• Past medical History, eg. DM, Epilepsy, Hx of chronic, liver, kidney,
lung, heart or other medical diseases
General examination 
• Assessing vital signs and the ABCs (airway patency, breathing
[ventilation and oxygenation], and circulation) are crucial for initial
stabilization, but may also provide clues about the underlying etiology
• Temperature – Hyperthermia suggests infection, but is also seen with
inflammatory disorders, environmental or exertional heat stroke,
neuroleptic malignant syndrome, status epilepticus, hyperthyroidism,
and anticholinergic poisoning.
• Hypothermia can occur with infection in infants but is more often due
to drug intoxication, environmental exposure, or hypothyroidism
• Heart rate – Tachycardia can occur with fever, pain, hypovolemia,
cardiomyopathy, tachyarrhythmia, and also in status epilepticus.
• Bradycardia occurs with hypoxemia, hypothermia, and increased ICP
as part of Cushing triad (bradycardia, hypertension, irregular
respirations).
• Respirations – Tachypnea can be seen with pain, hypoxia, metabolic
acidosis, and pontine injury.
• Slow, irregular, or periodic respirations occur with metabolic alkalosis,
diabetic ketoacidosis, sedative intoxication, and injury to extrapontine
portions of the brainstem
• Kussmaul’s respiration
- deep and rapid respiration
- suggests metabolic acidosis like DKA
• Cheyne-stokes respiration
- Periodic respiration
- Hyperpnea alternated with apnea
- Suggests diffuse cerebral hemisphere lesion
• Blood pressure – Hypotension suggests hypovolemic, septic, or
cardiogenic shock, intoxication, or adrenal insufficiency.
• Hypertension may be due to:
Pain or agitation
Certain toxidromes (eg, sympathomimetics, stimulants)
Increased ICP: Hypertension associated with bradycardia and
irregular respirations is referred to as "Cushing triad" in this setting
• Other physical findings:
Skin – The skin appearance provides useful information
Mottling and delayed capillary refill suggest a shock state
Bruising suggests traumatic injury (including abusive head trauma
Petechial and purpuric rashes may be suggestive of meningococcal
infection.
Jaundice may suggest hepatic encephalopathy.
A cherry-red appearance is suggestive of carbon monoxide poisoning.
Funduscopy – Papilledema suggests increased ICP of more than several
hours duration . Retinal hemorrhages are most commonly associated
with shaken baby syndrome.
• Meningismus – Meningeal irritation or inflammation suggesting
meningitis
• Neurologic examination — The neurologic examination in this
situation is necessarily brief and is directed at determining whether
the pathology is structural or due to a systemic metabolic
derangement (including drug toxicity or infection).
• Level of consciousness
• Pupil responsivity
• Brainstem reflexes: pupillary responses to light, extraocular
movements, and corneal reflexes
• Motor responses
 C) Glasgow coma scale & Modified
GCS

Eye opening Motor response

( Total points 4 ) (Total points 6 )
• Spontaneous 4 • Obeys 6
• To voice 3 • Localizes pain 5
• To pain 2 • Withdraws 4
• None 1 • Flexion 3
• Extension 2
• None 1
Verbal response
(Total points 5)

Older children Infants & young children

• Oriented 5 Appropriate words;
smiles , fixes,& follows
• Confused 4 Consolable crying

• Inappropriate words 3 Persistently irritable

• Incomprehensive sounds 2 Restless , agitated
• None 1 None
- Specifically for those who have sustained a
traumatic head injury
- It has also been used and being used in coma
due to nontraumatic etiologies
- Total score ranges 3-15
- Score of 8 or less = may require aggressive
management (coma)
Posture(with and with out noxious stimuli)
• Decorticate posture
-Flexion of the elbow ,fist & extension of the knee joint
-It suggests diffuse damage to cerebral hemisphere or lesion to
diencephalon.
• Decerebrate posture
- Extension of the elbow and wrist with abduction and
pronation of upper limb and extension of knee joint
- It suggests lesions of mid brain.
DIAGNOSTIC STUDIES 
• Laboratory testing — All patients presenting with altered
consciousness should undergo a rapid bedside test for blood glucose
and basic laboratory testing including:
• Serum electrolytes, calcium, magnesium, glucose
• Arterial or venous blood gas
• Liver function tests, ammonia
• Complete blood count with differential
• Blood urea nitrogen, creatinine
• Urine and serum toxicology screening
• Blood and urine cultures
• Neuroimaging — 
• X-ray
• CT scan of brain
• MRI of brain
• EEG
• Lumbar puncture — Urgent evaluation of cerebrospinal fluid (CSF) is
required when there is suspected infection of the central nervous system.
TREATMENT 
• Early treatment of coma is generally supportive until a definitive
diagnosis is made.
• An important goal of early treatment is to limit brain injury.
 ABC of life (Cardiopulmonary resuscitation)
- Emergency management
• Maintain respiration
- Airway, suctioning,O2
- Intubation and artificial ventilation may be
necessary
• Maintain circulation
- Treatment of shock or hypotension
• Secure IV line , draw blood
 Administer glucose
 Medical management of increased ICP
- limit fluid intake
- elevate head to 30
- Hyperventillation ( lower Pco2 to 30-35mmhg )
-Mannitol/furosemide
-Dexamethasone
 Correct electrolyte imbalance
 Symptomatic Rx of fever, urine retention, vomiting
 Combat infection
 Rx of seizure
Specific antidotes for poisoning
Specific Rx of underlying diseases
E.g. meningitis , malaria
 Coma care
Coma care
• Nutrition
- IV solutions initially , later NG tube feeding
• Frequent suction of the mouth,nose & oropharynx
• Skin/Position
- Turn patient every 2-3 hours to prevent decubitus ulcer
• Eyes(Cornea)
- Tape the patient’s eyelids shut
- Use eye ointments or drops
• Catheterize the urinary bladder
Neurosign chart
• Identification : Name , age , and • Meningeal signs
sex of the patient • Pupillary size & light reflex
• Date , time • Seizure
• V/S (BP,PR,RR,T) • Head circumference
• Respiratory pattern • Anterior fontannel
• Level of consciousness(Use GCS)
• Posture
• Focal neurologic deficit
Prognosis
• Coma is a transient state, usually lasting no more than two to four
weeks. prognosis Depends on causes of coma and early intervention.
• Better for metabolic coma
• Better for young children
• Worse for global hypoxic-ischemic events
Depth of coma
- No eye opening after 6 hours of coma…..only 10% have good or
moderate recovery
Duration of coma
- the longer the coma persists , the less likely the chance for
recovery
Brainstem reflexes : Signs of poor prognosis
1) Corneal reflex
- absent 24 hours after onset of coma
2) Pupilary reflex
- absent 24 hours after onset of coma
3) Roving eye sign
- absent by the 7th day of onset of coma
Referance
Uptodate
Nelson 21th edition