Approach To Child With Coma Flashcards
What is Coma?
Coma is an alteration in the level of consciousness in which the person appears to be asleep, cannot be aroused and shows no awareness of the environment
Levels of consciousness are regulated in what areas?
Regulated in two areas
1. Cerebral hemispheres
2. ARAS
Note: altered LOC Can affects one or both or communication between the two
What is ARAS?
Ascending reticular activating system
1. ARAS modulates arousal in response to external stimuli
- has targets in thalamus, hypothalamus and cerebral cortex
- healthy projections between the two areas are essential
2. located in the brainstem
What are the states of consciousness between normal levels of consciousness and coma?
i.e. spectrum
- Confusion
- Delirium
- Lethargy
- Obtundation
- Stupor
What questions do you ask in getting a history from a coma patient?
- Onset
- Acute vs gradual - Associated symptoms
- Fever, headache, rash, irritability, trauma, seizure - Reccurent episodes
- Family history
- Developmental delays
- Birth history
- Immunological state
- Events surrounding
- History of trauma
How do you assess a child with coma?
- State of consciousness
- Pattern of respiration
- Pupillary reactions
- Eye movements
- Motor function
Describe a coma score?
AVPU
1. awake - patient is awake
2. verbal - patient responds to a verbal stimulus
3. pain - patient responds to a pain stimulus
4. unresponsive - patient is unresponsive to stimulus
Describe pupillary reactions in a child with coma?
- Dolls eye movement (oculocephalic)
- when head is turned eyes move in the opposite direction - Caloric stimulation (Oculovestibular)
- ice water in the ear canal causes eyes to move in the direction of that ear
Why are pupillary reactions used in assessing consciousness?
- The area of the brain stem controlling consciousness and those controlling pupillary reactions are anatomically adjacent the pupils are a usefull guide in assessing consciousness
- The pupillary pathways are also relatively resistant to metabolic insults
What is the pattern of respiration in a healthy child?
Follow a Cephalo caudal progression
What are the changes in pattern of respiration in a child with coma?
- Post hyperventilation apnoea
- Cheyne stokes respirations
- Central neurogenic hyperventilation
- Apneustic breathing
- Ataxic breathing
What is seen upon inspection during motor exam in a child with coma?
- Fasciculations
- Wasting
- Posturing
- Gait
What do you test for during the motor exam of a child with coma?
- power
- Maximum effort a patient can exert from an individual/muscle groups - Reflexes
- Assess integrity of sensory and motor neuron circuit - tone
- sensory function
- Coordination
- Finger to nose test
- Heel shin test
Name causes of coma that causes no focal neurology / CSF abnormalities?
- Infection
- Shock
- Epilepsy
- Intoxication
- Metabolic
- Epilepsy
- Hypertensive encephalopathy
- Hyper/hypothermia
- Concussion
Name causes of coma that causes meningeal irritation with RBC/WBC in CSF?
- Subarachnoid heamorrhage
- Bacterial meningitis
- Viral encphelalitis
Name causes of coma that causes focal neurology without CSF abnormalities?
- Brain heamorrhage
- Cerebral infarction
- Brain abscess/ empyema
- Subdural/epidural heamorrhage
- Brain tumour
What is raised intracranial pressure?
Increase in volume of one or more of the intracranial compartments
1. CSF
2. Brain tissue
3. Blood
Consequences of raised intracranial pressure?
Raised ICP interferes with cerebral circulation resulting in hypoxia and ischaemia
Cerebral blood flow less than 20ml/kg/min results in ischaemic damage
CPP= MBP-ICP
Investigations?
RBG
FBC
Acute phase reactants
Urea+ Electrolytes
Blood culture
ABG
LFTs
Toxicology screen
Urinalysis
Neuroimaging?
CT scan
- Indicated in trauma, focal neurology, unclear etiology
What is the primary assessment and resuscitation in management of coma?
Airway - is it secure?
Breathing - is respiratory effort sufficient?
Circulation - treat shock
Disability - check blood glucose
- AVPU or Glasgow Coma Scale
Exposure - e.g. look for meningococcal purpuric rash
What is the secondary assessment and emergency treatment in management of coma?
- Examination
- Is there raised intracranial pressure - abnormal breathing, posture, pupils?
- Bradycardia and hypertension suggest impending brain stem herniation - Treat the treatable
- hypoglycaemia
- poisoning
- diabetes mellitus
- septicaemia/meningitis
- herpes simplex encephalitis
Note: Intubate and ventilate if necessary, transfer to paediatric/neurosurgical intensive care unit
Management?
- Infection
- Seizure control
- Detect and treat raised ICP
- Maintain microcirculation
- Maintain homeostasis
Note: Address rapidly reversible causes, initiate protective measure and begin time sensitive management steps
