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Comatose child
Consciousness
State of wakefulness with awareness of
self and surrounding .
Confusion
Altered consciousness (the subject misinterprets his
surrounding) .
Delirium
state of high arousal ( acute confusion ) There is
confusion and visual hallucination .
Stupor
Is abnormal sleepy stat from which the subject
can be aroused by repeated stimuli .
What is a coma ?
Coma ( or unconsciousness )
Is a state in which a patient is totally unaware of both
self and external surroundings.
Coma is not a disease. It is a symptom of
disease or a response to an event.
Pathophysiology:
A reduction in neuronal function
resulting from disruption of cerebral
cortical or brain stem integrity.
* Encephalopathy:
hypoxia
ischemia
seizures and post ictal states
* Infection:
encephalitis
meningitis
septicemia
* Pressure effects:
cerebral edema
hydrocephalus
space occupying lesions
* Vascular:
- hemorrhage :
extradural, subdural, subarachnoid, intraventricullar
- hypertensive encephalopathy
* Diseases of other systems:
- hepatic coma
- uremic encephalopathy
- respiratory failure with C02 narcosis
* Endocrine:
-
adrenal insufficiency
DKA / hypoglycemia
hypothyroidism
hypopituitarism
* Exogenous intoxication:
- sedatives
- salicylates
- heavy metals
- carbon monoxide
* Fluid and acid-base balance:
-
H20, Na, K, Mg and Ca imbalance
* Trauma.
How to approach
to comatose
patient ?
History
Infection:
Fever, irritability, lethargy, poor feeding, rash,
seizure.
Metabolic:
Hx of DM, hx of previous loss of consciousness,
hepatomegaly, jaundice, oligurea, hypertension.
Poisoning:
Ask about drugs in the family, tablets, and alcohol.
Seizure:
Past hx of seizure, neurocutaneous lesions,
developmental delay, abnormal eye movement,
focal neurological signs.
Trauma:
Hx of road traffic accident, fall, bruising, hemorrhage,
fractures.
Raised intracranial pressure:
Headache, vomiting,
focal neurological signs: ataxia, squint.
Papilloedema, retinal hemorrhage.
Physical Examination
General
Examination
Neurological
Examination
In General Examination
:
Vital Signs:-
PULSE
IRREGULAR – Cardiac diseases
ABSENT – Peripheral emboli
FEEBLE – Circulatory collapse
BLOOD PRESSURE
- CVA
- hypertensive
encephalopathy
- Cardiogenic shock
- Septicemia
- Addison’s disease
TEMPERATURE
FEVER
- Systemic infection : malaria
- Meningitis / encephalitis
- Heat stroke
HYPOTHERMIA
- Drugs : Barbiturate
- Circulatory failure
- Myxoedema
Skin and mucous membranes:-
JAUNDICE
CYANOSIS
PURPURA
SKIN RASH
Head - scalp :fractures, hematomas ,ant fontanels.
ENT :discharge, blood
Fundoscopy
Neck - Cx. Spine:fracture, neck stiffness, carotid pulses
Neurological examination
Determine level of consciousness by
GCS
* The Glasgow Coma Scale is used to
determine the severity of a brain injury.
It is often used at the emergency scene
or emergency room.
* The scale is used as part of the initial
evaluation of a patient, but does not
assist in making the diagnosis the cause
of coma
* Motor, verbal, and eye responses are
rated.
Spontaneous
Spontaneous
4
To loud voice
To loud voice
3
To pain
To pain
2
None
None
1
Eye
Opening
Verbal
Response
Oriented
smile, follows objects.
5
disoriented and
converses
spontaneous irritable
cry
4
inappropriate
words
Cries only to pain
3
Incomprehensible
sounds
Moans to pain
2
None
1
None
Motor
Response
Obeys commands
Obeys commands
6
Localizes pain
Localizes pain
5
Withdraws from
pain
Withdraws from
pain
Abnormal flexion
(decorticate
posture)
Abnormal flexion
(decorticate
posture)
Abnormal Extension AbnormalExtension
(decerebrate posture)
(decerebrate posture)
None
None
4
3
2
1
GCS
Mild=13-15
Moderate=9-12
Severe=3-8
Minimum=3 - Maximum=15
Core Neurological Exam (for coma);
1)Respiratory rate
2)Pupil
3)Extra ocular muscle, function muscle
4)Motor exam
5)Ciliospinal reflexes
MOTOR RESPONSE
METHODS OF ELICITING MOTOR RESPONSE
Supra-orbital
nail-bed
sternum
PUPILS – SIZE AND REACTION TO LIGHT
METABOLIC
Normal, reactive
DIENCEPHALIC
Small, reactive
III NERVE (UNCAL)
dilated, fixed
MIDBRAIN
Large, fixed
PONS
pinpoint
yes
(brain stem intact)
no
(brain stem damage)
- Chyne-Stoke breathing (cerebral
hemisphere lesion)
- Central Neurogenic
Hyperventilation (midbrain)
- Apneustic breathing (pons)
- Ataxic breathing – gasping (medulla)
INVESTIGATION
-Drugs screen(eg_salicylates
diazepam-narcotics-amphetamines)-Routine biochemistry (urea-electrolytesglucose-calcium-liver biochemistry)
-Metabolic and endocrine studies (TSH-serum
cortisol)
- Blood cultures
such as cerebral malaria(thick blood film)
-If the explanation remains unclear ,further
investigation are needed .
IMAGING
CT or MRI brain imaging may indicate an
otherwise unsuspected mass lesion or
intracranial hemorrhage.
CSF examination
Lumber puncture should be performed in coma
only after careful risk assessment .it is usually
contraindicated when an intracranial mass
lesion is a possibility .CT is necessary to
exclude this. CSF examination is likely to alter
therapy only if undiagnosed
meningoencephalitis or other identifiable
infection is present .
lumbar puncture….
Electroencephalography
EEG is of some value in the diagnosis of
metabolic coma and encephalitis .
Management of
comatose patient
Immediate Therapy
Specific Therapy
C
A
B