Approach to a child with coma
- 1. APPROACH TO A CHILD WITH COMA DR C ABHIRAM KUMAR SPECILAIST-PICU ASTER CMI HOSPITAL
- 2. O INTRODUCTION O ETIOLOGY-CLUES AND CUES O EXAMINATION O INVESTIGATION O MONITORING AND MANAGEMENT
- 3. O Consciousness- State of being awake and aware of self and surroundings O Arousal- Requires intact RAS O Awareness – Requires intact cerebral hemispheres
- 5. O Coma- Complete absence of arousal and awareness of self and environment lasting > 1hour. O Coma is a life threatening Pediatric emergency
- 6. Approach to the comatose child O Initial stabilization- ABCD’s O Airway- Positioning of the child Clearing of secretions Insertion of airway
- 7. O Breathing- Assess adequacy of breathing Supplemental O2 with NRM Ventilation(Bag and mask/tube) O Circulation- Assess circulatory status IV/Intraossoeus cannulation Fluid bolus/Inotropes
- 8. O Disability- Dextrostix, Correct hypoglycemia Control seizures C-spine stabilization Identify and treat raised ICT Intubate if GCS<8
- 9. O History O Physical Examination O Neurological Examination
- 14. History O Fever O Rash O Travel to another place O Seizures O Behavioral disturbances O Trauma O Exposure to toxins O Animal bites O Past medical illness O Family history
- 15. Examination of Vitals O Fever O Tachycardia/Bradycardia O Tachypnea/Altered breathing pattern O Hypertension/Hypotension
- 17. Neurologic Examination O Level of consciousness O Pupillary abnormalities O Breathing patterns O Posture and motor response O Signs of Raised ICP O Herniation syndromes
- 21. Motor Response O Appropriate Response- Withdrawal from the painful stimulus O Inappropriate Response- Decorticate or Decerebrate posturing O Flaccidity with absent response-ponto – medullary or lower brainstem lesion
- 23. Signs of Raised ICT O Headache O Vomiting O Bradycardia O Hypertension O Irregular breathing O Papilledema O 3rd or 6th cranial nerve palsy O Impairment of consciousness
- 26. Investigations
- 28. Management O Stabilize ABC’s O Identification and treatment of raised ICP O Neuroprotective measures O Treat seizures and continuous EEG monitoring O Correction of acid base and electrolyte abnormalities O Maintain normothermia and euvolemia
- 29. Specific Management Infections O LP for CSF analysis and culture O RT PCR/ME panel for encephalitis O Store 2 extra samples of CSF always O If LP contraindicated- Emperical Antibiotics(Cefftriaxone+/- Vancomycin) O Acyclovir for viral encephalitis O Antimalarial(Artesunate/Quinine) in endemic areas
- 30. ROLE OF STEROIDS O Useful in- ADEM Meningococcemia with shock Enteric Encephalopathy Tubercular meningitis Pyogenic meningitis Autoimmune Encephalitis Raised ICP with localised edema
- 31. O Antidotes for poisonings O Treat metabolic causes appropriately
- 32. Prognosis O Depends on cause of altered mental status O Infectious encephalopathies have better prognosis O Recovery of motor skills is better compared to cognitive deficits O Younger children with lower GCS scores who present in hypotension tend to have porer outcomes
- 33. Summary O Pediatric coma is an acute medical emergency which needs prompt evaluation and intervention O Stabilize ABC’s while simultaneously evaluating with effective history and accurate physical examination O Regardless of etiology general principles of management must be followed to improve neuronal recovery and outcome