An infant or child with an altered level of consciousness

Question 1

Etiology

Answer 1

Acute asphyxial event->birth, cardiac arrest, near miss cot death
Shock
Convulsions
Renal failure
Liver failure
Reye’s syndrome
Metabolic->hypoglycemia, diabetic ketoacidosis, inborn errors of metabolism
Raised intracranial pressure
Head injury
Meningitis/encephalitis
CVA->vasculitis, hypertension, thrombotic, malformations

Question 2

Important history

Answer 2

Possible drug?
Prodromal illness? Contact with serious illness
Assess possibility of non-accidental injury
History of convulsions and duration
Was the child neurodevelopmentally normal prior to the onset

Question 3

Examination

Answer 3

Vitals->look for bradyC (+ICP), tachyA (drugs). Deep sighing (kussmaul’s). Ketones smelt on breath.
Look for fucus of infection. Check for rashes and neck stiffness, pneumonia and UTI.
Check pupils are symmetrical and do the constrict appropriately to light?
Check for abnormal posturing
Assess LOC w/ AVPU or GCS
Always check blood glucose

Question 4

What is the most common metabolic cause of coma

Answer 4

Hypoglycemia

Question 5

Investigations and their significance (11)

Answer 5

Blood glucose->hyper/hypoG
FBE->infection or acute blood loss
Blood culture
UEC->High urea in deH, sodium may be high or low
Blood gases->metabolic or respiratory acidosis
CXR->infection or cardiac failure, trauma
CT/MRI->Focal pathology: tumor, abscess, hemorrhage
LP->infection or bleeding
Metabolic screen->ammonia + in urea cycle defects and Reye’s
LFTs->hepatic encephalopathy
Urine->toxicology screen for poisoning or overdose

Question 6

What does a score of P corresponds to a GCS of… and what does it suggest needs to be done.

Answer 6

Corresponds to a GCS of 8 and the airway needs to be protected to prevent intubation

Question 7

What does coma mean

Answer 7

Pre-comatose state with altered level of consciousness

Question 8

Viral causes of meningitis

Answer 8

Mumps
Coxsackie
Echovirus
Herpes simplex
Poliomyelitis

Question 9

Bacterial causes of meningitis

Answer 9

N, meningitidis
S. pneumoniae
Haemophilus influenzae type B
Group B streptococcus
Escherichia  coli and listeria

Question 10

Three situations when a LP is not to be done

Answer 10

When +ICP or chance of
When hemodynamically unstable
When thrombocytopenia/coagulopathy

Question 11

Analysis of CSF in viral/bacterial meningitis- appearance, white cells, protein, glucose

Answer 11

Bacterial: Turbid w/ prganisms, +++PMN, ++protein, low glucose
Viral: Clear, +lymphocytes, N protein N glucose

Question 12

treatment of encephalitis (antiB and antiV)

Answer 12

Aciclovir
Erythromycin
Cefotaxime

Question 13

Presentation of Reye’s

Answer 13

May be precipitated followed administration of aspirin during a viral illness in young children
Vomiting and lethargy->inflammatory encephalopathic illness with personality change, irritability, coma with +ICP.
Supportive therapy + ICU Mx of +ICP