Chapter 6 Child with decreased conscious level

Question 1

What are the categories of illness that can cause decreased GCS?

Answer 1

Hypoxic ischaemic brai injury
Epileptic seizures
Trauma (head injury)
Infection (meniningoencephalitis, malaria)
Intoxication
Metabolic (hepatic, renal, glucose, hypothermia, hypercapnea, inherited metabolic disease)
Cerebrovascular event (AV malformation, tumour)
Hydrocephalus

Question 2

Using the Glasgow coma scale in those less than 4, does scoring of eye response change in comparison to adults?

Answer 2

No, it’s the same
4 = spontaneous
3 = to verbal
2 = to pain
1 = no response

Question 3

How does the Best Motor Response in the GCS change for children < 4

Answer 3

6 = spontaneous activity OR obeys commands
5 = localises to pain or withdraws to touch
4 = withdraws from pain
3 = abnormal flexion to pain (decorticate)
2 = abnormal extension to pain (decerebrate)
1 = no motor response

Question 4

How does the Best Verbal Response of the GCS change for children < 4

Answer 4

5 = Alert, babbles, coos, words to usual ability
4 = less than usual words, spontaneous irritable cry
3 = cries only to pain
2 = moans to pain
1 = no response to pain

Question 5

describe Central syndrome

Answer 5

when the whole brain is pressed down towards the foramen magnum and the cerebellar tonsils herniate through - coning

Neck stiffness
Bradycardia
HTN
Irregular respiration

Question 6

describe Uncal syndrome

Answer 6

increase in the intracranial volume, mainly in the supratentorial space, leading to the uncus (part of the hippocampal gyrus) being forced through the tentorial opening and becoming compressed. If the compression is unilateral e.g a subdural or extradural haemorrhage

CN III palsy - ipsilateral dilated pupil (mydriasis)

ptosis of the affected eye

occulomotor palsy with the eye displaced laterally and downward

unable to abduct eye

unilateral uncal herniation = Hemiplegia

Question 7

What is the IV dose of glucose for hypoglycaemia?

Answer 7

3ml/kg of 10% glucose

Question 8

At what BSL should you treat with IV glucose?

Answer 8

< 3mmol/L

Question 9

After giving a bolus of glucose for hypoglycaemia, what infusion should you follow it with

Answer 9

Infuse 5% glucose to prevent rebound hypoglycaemia (may be due to ongoing event causing hypoglycaemia or due to large gluclose bolus)

Question 10

What blood sample should you obtain (ideally) prior to treating a first ever episode of hypoglycaemia?

Answer 10

Lithium heparin tube to allow further investigation of cause

Question 11

In addition to checking LFTs when you suspect decrease GCS due to liver failure, what test might you order that could assist?

Answer 11

ammonia level

Question 12

Is the fontanelle bulging or flat in meningitis?

Answer 12

Bulging

Question 13

What is the dose of hypertonic saline for raised ICP?

Answer 13

3% NaCl 3ml/kg over 15-30 minutes
then 0.1 to 1ml/kg/hr
Do not exceed osmolality > 360mOsm/L

Question 14

Is dexamethasone use for generalised cerebral oedema?

Answer 14

No, only useful for oedema surrounding a space occupying lesion
0.5mg/kg/hr 6 hourly

Question 15

Can ICP still be raised with normal fundi examination and CT scan

Answer 15

Yes. Don’t perform LP in a sick child or child with decreased GCS

Question 16

When is an LP contraindicated?

Answer 16

Signs of decreased GCS
Seizures
Thrombocytopaenia or coagulation disorder

Question 17

If the cause of coma cannot be clearly explained by another cause, what must you assume and provide early treatment for?

Answer 17

Meningitis

Question 18

What are most of the signs of menigitis due to?

Answer 18

Raised ICP: headache, photophobia, neck stiffness, vomiting, seiures, coma

Question 19

Why would you add on a macroide when treating meningitis?

Answer 19

For the rare possibility of mycoplasma encephalitis.
Treat in all comatose febrile children

Question 20

When should you give dexamethsone when treating meningitis?

Answer 20

ASAP but within 4 hours of antibiotics. No later than 12 hours from antibiotics.

Question 21

What is the role of dexamethsone in treating meningitis?

Answer 21

Reduces rate of severe hearing loss and possible other long term neurological sequalae.
Can’t give if < 3 months

Question 22

What is the dose of naloxone?

Answer 22

10mcg/kg

Question 23

How does normalising CO2 prior to giving naloxone help

Answer 23

Helps reduce risk of sudden rise in sympathetic activity (risk of VT, APO)

Question 24

In a very young child, what do these features suggest?
Hepatomegaly
Hypoglycaemia
Abnormal LFTs
Hyperammonaemia

Answer 24

Inborn errors of metabolism

Question 25

How do inborn errors or metabolism present to ED?

Answer 25

Progressive encephalopathy
Vomiting
Drowsiness
Convulsions
Coma

Question 26

Why should ammonia levels be checked in a child with unexplained decreased GCS?

Answer 26

To check for inborn errors of metabolism (lithium heparin tube)

Question 27

In a child who has return from overseas, what do these features suggest?

Reduced GCCS
Metabolic acidosis
Hypoglycaemia
Severe normocytic anaemia

Answer 27

Malaria - 95% of severe malaria from plasmodium flaciparum

Question 28

Where does locked in syndrome effect the brain?

Answer 28

usually the pons

unable to move or speak but retain awareness

may retain voluntary eye movement and blinking

Question 29

describe Cerebral perfusion pressure

Answer 29

CPP = MAP - ICP

aim for CPP>40-60mmHg

Question 30

describe common causes for a fixed dilated pupil in a child?

Answer 30

during or post seizure

drugs such as anticholinergics

or

barbiturates (late sign)

hypothermia

severe hypoxia

Question 31

describe common causes for a small or pin point pupils in children?

Answer 31

opiates

metabolic disorders

medullary lesions

organophosphate poisoning

Question 32

describe common causes for a unilateral dilated pupil?

Answer 32

CN3 palsy

rapidly expanding ipsilateral lesion

focal epileptic seizures

Question 33

what are the top 3 causes of coma in a child?

Answer 33

95% = cerebral hypoxia and ischaemia

5% = structural lesions

Question 34

what are the 4 components of the D section of A-E

Answer 34

Conscious level

Posture

Pupils

Glucose estimate

Question 35

Paediatric GCS

Answer 35

Question 36

fixed mid-size pupil cause?

Answer 36

midbrain lesion

Question 37

management of raised ICP

Answer 37