Coma means dysfunction of either the

8/7/2019 Coma means dysfunction of either the

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Coma indicates dysfunction of C.N.SComa indicates dysfunction of C.N.S

Primary or Secondary to other disease processPrimary or Secondary to other disease process

Pontine reticular activating system (BrainPontine reticular activating system (Brain

stem) is invovedstem) is invoved

Bihemispheric Cerebral DysfunctionBihemispheric Cerebral Dysfunction Extensive Cerebral involvementExtensive Cerebral involvement


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ComaComa CausesCauses Head TraumaHead Trauma

HypoxicHypoxic IschemicIschemic : Shock, Anaphylaxis, Near drowning: Shock, Anaphylaxis, Near drowning

InfectionInfection Meningitis & Encephalitis (Viral, Bacterial etc);Meningitis & Encephalitis (Viral, Bacterial etc);Brain abscess, Malaria, Sepsis, TyphoidBrain abscess, Malaria, Sepsis, Typhoid

I.C.PI.C.P -- Cerebral edema (Vasogenic, Cytotoxic),Cerebral edema (Vasogenic, Cytotoxic),ICSOLICSOLPseudotumor CerebriPseudotumor Cerebri

Metabolic EncephalopathyMetabolic Encephalopathy -- Hypo / Hyperglycemia (DKA)Hypo / Hyperglycemia (DKA)Hypo / Hypernatremia,Hypo / Hypernatremia,Hyperammonemia, Reyes syndromeHyperammonemia, Reyes syndromeHepatic, Renal, & Respiratory failureHepatic, Renal, & Respiratory failureDrugs, Poisons.Drugs, Poisons.

SeizuresSeizures -- Status & Postictal stateStatus & Postictal state

VascularVascular Stroke, Vasculitis, Systemic Hypertension, Vascular malformationStroke, Vasculitis, Systemic Hypertension, Vascular malformation


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Comatose Patient

Primary Objectives

Airway Breathing Circulation

Life Saving Rx FirstSpecific Dx Next

Rx rapidly progressive,

dangerous

metabolic causes

(hypoglycemia)

Ex & Rx ICP

If mass lesions

Surgical Rx - SOS

Rx Seizures,Temp,O2,

Fluid,Electrolyte &

Acid-Base;

Mx Brain-stem Function


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ICPICP -- 44


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ICPICP 99

What if ICP increases?What if ICP increases?

With >ICP herniation of brain can occur,With >ICP herniation of brain can occur,at 3 anatomic sites.at 3 anatomic sites.

Impinging on nerves & blood vessels.Impinging on nerves & blood vessels.

Leading to neuronal dysfunction &Leading to neuronal dysfunction &cerebral edema.cerebral edema.


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Uncal herniation (transtentorialUncal herniation (transtentorial through tentorial notch )through tentorial notch )into posterior fossainto posterior fossa


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Cerebellar herniation (through foramen magnum)Cerebellar herniation (through foramen magnum)


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ICPICP -- 66

Signs & symptoms depend onSigns & symptoms depend on

1. Age of child.1. Age of child.

2. Rate of rise of ICP2. Rate of rise of ICP


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ICPICP -- 77 ACUTE INCREASEACUTE INCREASE

SYMPTOMSSYMPTOMS

Consciouness alterationConsciouness alteration

CryingCrying

Gaze abnormalityGaze abnormality

HeadacheHeadacheIrritabilityIrritability

LethargyLethargy

VomitingVomiting

SIGNSSIGNS

ComaComa

Cranial.N 3Cranial.N 3rdrd & 6& 6thth palsiespalsies

Cushing triadCushing triad (late sign)(late sign)

BradycardiaBradycardiaHypertensionHypertension

RespirationRespiration irregularityirregularity

Decorticate / DecerebrateDecorticate / Decerebrate

posturepostureSetting sun sign (impairedSetting sun sign (impairedupper gaze)upper gaze)


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ICPICP 88SLOW INCREASESLOW INCREASE

SYMPTOMSSYMPTOMS

Early morningEarly morningheadacheheadache

Vomiting withoutVomiting without

nauseanausea

Personality changesPersonality changesLethargyLethargy

FatigueFatigue

DrowsinessDrowsiness

Memory loss,


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BRAIN STEM FUNCTIONSBRAIN STEM FUNCTIONS


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Comatose PatientComatose Patient -- Secondary ObjectivesSecondary Objectives

Understand and recognize:Understand and recognize: Coma (Level of Consciousness)Coma (Level of Consciousness) Degree,Degree,

Duration.Duration.

Signs of supratentorial mass lesionsSigns of supratentorial mass lesions

Signs of subtentorial mass lesionsSigns of subtentorial mass lesions

Develop the differential diagnosis ofDevelop the differential diagnosis ofaltered level of consciosness.altered level of consciosness.


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Documentation of the level of comaDocumentation of the level of coma

ImportantImportant

1.1. Progressive deterioration indicatesProgressive deterioration indicates--brainbrain--stem compression.stem compression.

2.2. Often a stable or improving level of awarenessOften a stable or improving level of awareness-- metabolic causes of coma;metabolic causes of coma;

-- an intrinsic brainan intrinsic brain--stem lesionstem lesion --

Detect subtle changes in the level ofDetect subtle changes in the level ofconsciousness by careful description of theconsciousness by careful description of thepatient's response to specific stimulipatient's response to specific stimuli


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Glasgow Coma ScaleGlasgow Coma Scale

TestTest ResponseResponse ____ Score_____ Score_

EyeEye NoneNone 11 OpeningOpening To painTo pain 22 To verbal stimuliTo verbal stimuli 33 SpontaneouslySpontaneously 44

BestBest NoneNone 11 VerbalVerbal Incomprehensible wordsIncomprehensible words 22 ResponseResponse Inappropriate wordsInappropriate words 33 Disoriented conversationDisoriented conversation 44 Oriented conversationOriented conversation 55

BestBest NoneNone 11 MotorMotor Abnormal extensionAbnormal extension 22 R

esponseR

esponse Abnormal flexionAbnormal flexion 33 Flexion withdrawalFlexion withdrawal 44 Localizes painLocalizes pain 55 ______________________ Obeys commandsObeys commands ______ 6 _______ 6 _

Total scoreTotal score 33--1515


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GCS arbitrarily defines coma asGCS arbitrarily defines coma as

Failure to open eyes in response to verbalFailure to open eyes in response to verbalcommand (E2)command (E2)

Perform no better than weak flexion (M4)Perform no better than weak flexion (M4)

Utter only unrecognizable sounds inUtter only unrecognizable sounds inresponse to pain (V2).response to pain (V2).


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Coma Scales are measurements of ConsciousnessComa Scales are measurements of Consciousness(Rank ordered or semiquantitative)(Rank ordered or semiquantitative)

The GCS is of no diagnostic valueThe GCS is of no diagnostic value CauseCauseof Coma is not diagnosed.of Coma is not diagnosed.

Reliable way of objectively monitoring theReliable way of objectively monitoring theclinical course of the patient with an acuteclinical course of the patient with an acutecranial insult.cranial insult.


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Paediatric Coma ScalePaediatric Coma Scale(Simpson & Reilly)(Simpson & Reilly)

Eyes openEyes open Best verbal responseBest verbal response Best motor responseBest motor response

Spontaneously (4)Spontaneously (4)

To speech (3)To speech (3)

To pain (2)To pain (2)

None (1)None (1)

Orientated (5)Orientated (5)

Words (4)Words (4)

Vocal sounds (3)Vocal sounds (3)

Cries (2)Cries (2)

None (1)None (1)

Obeys command (5)Obeys command (5)

Localizes pain (4)Localizes pain (4)

Flexion to pain (3)Flexion to pain (3)

Extension to pain (2)Extension to pain (2)

None (1)None (1)


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Blantyre Coma ScaleBlantyre Coma Scale

Best motorBest motorresponseresponse

Verbal responseVerbal response Eye movementsEye movements

Localizes painfulLocalizes painful

StimulusStimulus 22

Withdraws limbWithdraws limbfrom Painfrom Pain 11

Nonspecific orNonspecific or

Absent responseAbsent response 00

Appropriate cryAppropriate cry 22

Inappropriate cry orInappropriate cry orMoanMoan 11

NoneNone 00

DirectedDirected 11

(e.g. follows mother's face)(e.g. follows mother's face)

Not directedNot directed 00

TOTALTOTAL SCORESCORE 00--55


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Diagnosis of comaDiagnosis of coma

SupratentorialSupratentorial

LesionsLesions

InfratentorialInfratentorial

LesionsLesions

Toxic, Metabolic,Toxic, Metabolic,Infectious processesInfectious processes

Initial signs focalInitial signs focal

RostrocaudalRostrocaudal

progressionprogression

AsymmetricAsymmetricneurological signs atneurological signs atonsetonset

Seizures may beSeizures may be

presentpresent

Initial S/O brain stemInitial S/O brain stemdysfunction may bedysfunction may bepresentpresent

Sudden ComaSudden Coma

Cranial nerve palsyCranial nerve palsycommoncommon

Respiratory patternsRespiratory patternsoften Alteredoften Altered

Confusion/StuporConfusion/Stupor

often precedeoften precede

motor signsmotor signs

SymmetricalSymmetricalneurological findingsneurological findings

Pupillary reactionsPupillary reactions

preservedpreserved

Respiratory rate oftenRespiratory rate oftenalteredaltered


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Diagnosis of comaDiagnosis of comaDiagnosticDiagnosticcategorycategory

Diagnostic featuresDiagnostic features

MetabolicMetabolic Normal pupil responses;Normal pupil responses;

Normal or absent eye movements depending on depth ofNormal or absent eye movements depending on depth ofcoma;coma;

Suppressed, Cheyne Stokes, or ketotic respiration;Suppressed, Cheyne Stokes, or ketotic respiration;

Symmetrical limb signs usually hypotonicSymmetrical limb signs usually hypotonic

Brainstem:Brainstem:intrinsicintrinsic

From outset: Abnormal pupil responses;From outset: Abnormal pupil responses;Abnormal eye movements;Abnormal eye movements;

Abnormal respiratory pattern;Abnormal respiratory pattern;

Cranial nerve signs;Cranial nerve signs;

Bilateral long tract signsBilateral long tract signs

BrainstemBrainstem

CompressionCompression

Papilloedema; Hemiparesis;Papilloedema; Hemiparesis;

Progressive: Loss of pupillary responses; eye movements;Progressive: Loss of pupillary responses; eye movements;

Abnormal respiratory patternAbnormal respiratory pattern

and/orand/or

LongLong--tract signs; Appearance of 3rd nerve palsytract signs; Appearance of 3rd nerve palsy


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ICPICP -- 1010

Management of COMAManagement of COMA

AAirway &irway & BBreathingreathing Intubation if Glasgow comascaleICP.Aspiration, >BP, >ICP.

So recommended methodSo recommended method Rapid sequence induction & SellickRapid sequence induction & Sellick

manoeuvermanoeuver -- cricoid pressure)cricoid pressure)

CCirculationirculation Normovolemeia, Normotension,Normovolemeia, Normotension,Hypertension (vasopressor induced)Hypertension (vasopressor induced)if ICP is refractoryif ICP is refractory


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ICPICP -- 1111

MANAGEMENTMANAGEMENT ICPICP

HyperventilationHyperventilation PaCo2: 30 to 35 mmHg, if less may cause cerebralPaCo2: 30 to 35 mmHg, if less may cause cerebralischemiaischemia

Elevation of head to 30 degreeElevation of head to 30 degree

MannitolMannitol --


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Seizures ManagementSeizures Management

DiazepamDiazepam

LorazepamLorazepam

MidazolamMidazolam

PhenytoinPhenytoin / Fosphenytoin/ Fosphenytoin

PhenobarbitonePhenobarbitone

Valproic acid I.VValproic acid I.V

Thiopental / PentobarbitalThiopental / Pentobarbital


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Supportive TherapySupportive Therapy -- OtherOther

EuglycemiaEuglycemia

Fluid & ElectrolytesFluid & Electrolytes

AcidAcid--Base statusBase status

TemperatureTemperature


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SPECIFIC THERAPYSPECIFIC THERAPY

Depends on CauseDepends on Cause

AntiAnti--infective therapyinfective therapy

Metabolic correctionMetabolic correction Glucose; InsulinGlucose; Insulin


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HydrocephalusHydrocephalus


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MeningoEncephalitisMeningoEncephalitis Brain abscessBrain abscess

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Coma means dysfunction of either the

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