Chapter 6 Child with decreased conscious level Flashcards
What are the categories of illness that can cause decreased GCS?
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
Using the Glasgow coma scale in those less than 4, does scoring of eye response change in comparison to adults?
No, it’s the same
4 = spontaneous
3 = to verbal
2 = to pain
1 = no response
How does the Best Motor Response in the GCS change for children < 4
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
How does the Best Verbal Response of the GCS change for children < 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
describe Central syndrome
when the whole brain is pressed down towards the foramen magnum and the cerebellar tonsils herniate through - coning
Neck stiffness
Bradycardia
HTN
Irregular respiration
describe Uncal syndrome
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
What is the IV dose of glucose for hypoglycaemia?
3ml/kg of 10% glucose
At what BSL should you treat with IV glucose?
< 3mmol/L
After giving a bolus of glucose for hypoglycaemia, what infusion should you follow it with
Infuse 5% glucose to prevent rebound hypoglycaemia (may be due to ongoing event causing hypoglycaemia or due to large gluclose bolus)
What blood sample should you obtain (ideally) prior to treating a first ever episode of hypoglycaemia?
Lithium heparin tube to allow further investigation of cause
In addition to checking LFTs when you suspect decrease GCS due to liver failure, what test might you order that could assist?
ammonia level
Is the fontanelle bulging or flat in meningitis?
Bulging
What is the dose of hypertonic saline for raised ICP?
3% NaCl 3ml/kg over 15-30 minutes
then 0.1 to 1ml/kg/hr
Do not exceed osmolality > 360mOsm/L
Is dexamethasone use for generalised cerebral oedema?
No, only useful for oedema surrounding a space occupying lesion
0.5mg/kg/hr 6 hourly
Can ICP still be raised with normal fundi examination and CT scan
Yes. Don’t perform LP in a sick child or child with decreased GCS
When is an LP contraindicated?
Signs of decreased GCS
Seizures
Thrombocytopaenia or coagulation disorder
If the cause of coma cannot be clearly explained by another cause, what must you assume and provide early treatment for?
Meningitis
What are most of the signs of menigitis due to?
Raised ICP: headache, photophobia, neck stiffness, vomiting, seiures, coma
Why would you add on a macroide when treating meningitis?
For the rare possibility of mycoplasma encephalitis.
Treat in all comatose febrile children
When should you give dexamethsone when treating meningitis?
ASAP but within 4 hours of antibiotics. No later than 12 hours from antibiotics.
What is the role of dexamethsone in treating meningitis?
Reduces rate of severe hearing loss and possible other long term neurological sequalae.
Can’t give if < 3 months
What is the dose of naloxone?
10mcg/kg
How does normalising CO2 prior to giving naloxone help
Helps reduce risk of sudden rise in sympathetic activity (risk of VT, APO)
In a very young child, what do these features suggest?
Hepatomegaly
Hypoglycaemia
Abnormal LFTs
Hyperammonaemia
Inborn errors of metabolism
How do inborn errors or metabolism present to ED?
Progressive encephalopathy
Vomiting
Drowsiness
Convulsions
Coma
Why should ammonia levels be checked in a child with unexplained decreased GCS?
To check for inborn errors of metabolism (lithium heparin tube)
In a child who has return from overseas, what do these features suggest?
Reduced GCCS
Metabolic acidosis
Hypoglycaemia
Severe normocytic anaemia
Malaria - 95% of severe malaria from plasmodium flaciparum
Where does locked in syndrome effect the brain?
usually the pons
unable to move or speak but retain awareness
may retain voluntary eye movement and blinking
describe Cerebral perfusion pressure
CPP = MAP - ICP
aim for CPP>40-60mmHg
describe common causes for a fixed dilated pupil in a child?
during or post seizure
drugs such as anticholinergics
or
barbiturates (late sign)
hypothermia
severe hypoxia
describe common causes for a small or pin point pupils in children?
opiates
metabolic disorders
medullary lesions
organophosphate poisoning
describe common causes for a unilateral dilated pupil?
CN3 palsy
rapidly expanding ipsilateral lesion
focal epileptic seizures
what are the top 3 causes of coma in a child?
95% = cerebral hypoxia and ischaemia
5% = structural lesions
what are the 4 components of the D section of A-E
Conscious level
Posture
Pupils
Glucose estimate
Paediatric GCS
fixed mid-size pupil cause?
midbrain lesion
management of raised ICP
