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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