COMA IN PEDIATRICS

DR DONALD P
OYATSI.
LECTURER/
CHILD NEUROLOGIST.
Definitions

• State of deep unarousable unconsciousness.

• Total loss of awareness of self & environ.
• Absence of wakefulness.
• Should last more than an hour.
Definitions

• Sleep: unawareness with normal brainstem function

• Delirium: abnormal mental state characterised by
 Loss of awareness of self & environ.
 Abnormal behaviour- motor & sensory.
 Misperception of stimuli.
 Memory impairment, talkative, aggressive.
• Stupor:
 Impaired consciousness with minimal mental reactivity.
 Responsive to aggressive stimuli.
Aetiological Classification

 Traumatic
 Non Traumatic
Aetiological Classification

 Traumatic
– Non accidental (head) injury.
– Other accidents
– Birth injuries
Non Traumatic coma.

 Hypoxic ischaemic encephalopathy.

– Near drowning
– Perinatal asphyxia
– Cardiorespiratory arrest
– Suffocation.
Non Traumatic coma.

 Primary CNS Infections.

– Meningitis
– Encephalitis
– Abscess
 Systemic infection with CNS involvement.
– Septicaemia
– Malaria
Non Traumatic coma.

 Metabolic disorders.
– Hypoglycaemia
– Hyperglycaemia
– Electrolyte imbalance.
– Acid base imbalance.
– Renal failure.
– Liver disease.
Non Traumatic coma.

 Cerebrovascular disorders.
– Intracranial haemorrhage
– Intracerebral ischaemic disease.
– Encephalopathy of sickle cell disease.
Non Traumatic coma.

 Toxins / Poisons / Drugs.

– Organophosphates/ carbamates
– Anti epileptic drug effect.
– Alcohol.
– Opiates/ addictive drugs.
Non Traumatic coma.

 Seizures.

 Endocrine abnormalities.

 Structural & degenerative CNS disease.

What maintains a conscious state.

 Neuronal network activity linking the cerebral

hemisphere, the cerebellum, the basal
ganglia, and thalamus.
 Coordination at the Reticular Activating
System.
 Vegetative state: dysfunction of the cortex in
a normally functioning brainstem.
Useful physiological changes in coma.

 Ocular changes: Motility and pupillary size.

– Oculocephalic & oculo-vestibular responses are lost in
brainstem lesions and diffuse hemispheric lesions.
– Small constricted pupils responsive to bright light
 Metabolic encephalopathy
 Diencephalic lesions
 Barbiturates poisoning.
Useful physiological changes in coma.

 Ocular motility and pupillary size changes.

– Dual para- and sympathetic injury in the mid brain results in
fixed pupils non reactive to light.
– Oculomotor nerve injury causes fixed dilated pupil
– Pinpoint pupils occur in
 Organophosphate poisoning
 Pontine lesion
 Narcotic poisoning
Useful physiological changes in coma.

 Motor responses
– Variable depending on focus of the lesion.
– Decerebrate posturing seen in diffuse cerebral
lesion.
Useful physiological changes in coma.

 Respiration
– Chyne stokes respiration in
 Lower cerebral hemisphere dysfunction
 Diencephalon or pontine lesion.
– Central neurogenic hyperventilation in rostral brainstem
tegmentum pathologies
– Ataxic breathing in medullary respiratory centre disease.
– Cluster breathing in pontine respiratory control centre.
Assessment of patient in coma.

 Glasgow coma scale.

 AVPU
Assessment of patient in coma.

 Glasgow coma scale.

– Best verbal response.
– Motor response.
– Eye opening.
 Modified for paediatric age group.
Assessment of patient in coma.

Paediatric Glasgow coma scale.

 Eye opening
– Spontaneous---------4
– To speech------------3
– To pain---------------2
– No response----------1
Assessment of patient in coma.

Paediatric Glasgow coma scale.

 Best Motor response.
– Spontaneous-----------6
– Withdraws to touch---5
– Withdraws to pain----4
– Abnormal flexion-----3
– Abnormal extension--2
– No response------------1
Assessment of patient in coma.

Paediatric Glasgow coma scale.

 Best verbal response.
– Oriented---------------5
– Confused--------------4
– Inappropriate----------3
– Incomprehensible-----2
– No response-----------1
Modified for paediatric age group > 2 years.
Assessment of patient in coma.

Paediatric Glasgow coma scale.

 Best verbal response.
– Oriented, social smile--------5
– Cries consolable--------------4
– Inappropriate, persitent cry--3
– Agitated, restless--------------2
– No response--------------------1
Modified for paediatric age group < 2 years.
Assessment of patient in coma.

Paediatric Glasgow coma scale.

 Maximum score 15 points
 Mild coma is 12-14.
 Moderate coma is 08-11
 Deep coma <8 points.
Coma – clinical evaluation.

 Prompt & thorough.

 Examination
– Temp
– Respiratory rate and pattern
– Smell the breath.
– Blood pressure
– Look out for bruises/ swellings
Coma – clinical evaluation.

 Prompt & thorough.

 Examination
– Ears:haemorrhage or csf leaks
– Eyes
 Corneal reflex disappear in late coma.
 Pupil size and reaction to light.
 Retinal haemorrhage.
 Oculocephalic / oculovestibular responses.
Coma – clinical evaluation.

 Prompt & thorough.

 Examination
– Nose for epistaxis
– Motor activities
– Fontanelles and sutures
– Neck stiffness: meningitis, subarachnoid haemorrhage,
neck injuries.
– Seizures:generalised or focal.
– Grade the coma as above.
Coma – lab assessment.

 Random blood sugar

 Haemogram
 Electrolytes
 Liver function tests
 Blood
 CSF studies
 Urine examination
Coma – lab assessment.

 Xrays – skull, abdomen.

 CT scans.
 MRI scans
 EEG
 BAEP/ SSEP
 Arteriography.
Coma

 Treatment
– Supportive ABC
– Definitive care of primary cause.
Coma – clinical evaluation.

 Prompt & thorough.

 Assess the ABC.
 Concise but thorough history
– Onset
– Events related to the state
 Fevers
 Seizures
 Trauma
 Drug ingestion.
Coma.

 Prognosis
– Cause of coma.
– Coma duration
– Interventition offered
– Facilities.
Coma.

 Outcome
– Full recovery
– Cognitive decline /arrest.
– Dementia
– Seizures.
– Motor dysfunction.
– Language disorder.
– Death.