1. By: LWANGA HERBERT FELIX
UWERA BENITAH
Tutor: Dr. Kalubi Peters
10/18/2023
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2. Definitions
Neuro-anatomy & physiology of normal consciousness Vs
Coma
Conditions that mimic Coma
Coma Etiologies
Coma Assessment scales (GCS, BCS, AVPU)
Approach to a convulsing/ Comatose child i.e Hx and P/E
Investigations
Management of a convulsing child & Status epilepticus
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3. 1. Seizure: Abnormal excessive electrical firing, or neuronal
activity in the brain which may result into
motor(contraction of muscles) or non motor(such as loss of
awareness, incontinence, drooling, yawning among others)
results
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4. It can either be epileptic OR non-epileptic
Epileptic: manifestation due to abnormal synchronous
neuronal activity in the brain
Non-epileptic seizure: mimics seizures but have nothing to do
with the brain, e.g. Shivering
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5. 2. Fit: Abnormal electrical activities in the brain that occur quickly
and can go almost unnoticed.
3.Spasm: A sudden involuntary muscle contraction.
4.Convulsions: Motor manifestation of a seizure.
Can be classified into
a) Generalized:
Tonic: Extension
Clonic: Flexion
Tonic-clonic: Both extension and flexion
Myoclonic: Localised to muscle
Atonic: Loss of tone, can lead to sudden falls
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6. b) Focal
Either motor, or non-motor
5. Coma: Prolonged state of unconsciousness in which a person
cant be awakened and is unresponsive to stimuli (e.g light,
pain, sound) and lacks a normal sleep-wake cycle, and doesn’t
initiate voluntary actions.
6. Epilepsy: A neurological disorder marked by sudden recurrent
episodes of sensory disturbance, loss of consciousness/
convulsions due to abnormal electrical activity in the brain.
It needs at-least 2 unprovoked seizures occurring more than
24hrs apart.
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7. 7. Status epilepticus: An afebrile seizure lasting more than 15
minutes, or Recurrent seizures lasting in total more than 30
minutes without return to consciousness in between.
8. Febrile Convulsions: A seizure of infancy/ childhood (1 month-
5yrs) associated with fevers but without evidence of
intracranial infection or a defined cause (such as trauma)
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8. Febrile Convulsions: convulsions precipitated by fever, not due to an
intracranial infection or other definable CNS.
Features:
Fevers >38℃
No neurological abnormality in the period between episodes
Usually brief convulsions and benign
Age dependent and occur between 6months and 5years of age.
Types
a. Simple Febrile convulsions (85%):
Brief Generalized tonic-clonic seizure lasting a few seconds to a
few minutes, usually <5mins followed by full recovery, and don’t go
beyond 15mins. Don’t recur within 24hrs.
a. Complex/Atypical Febrile Convulsions(15%): prolonged
(>15mins)repeated convulsions occur within the same day
(reccur more than once within 24 hours), when the seizure is
focal(confined to one side of the body) or post-ictal focal deficit
noted.
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9. Simple Febrile Convulsions:
low risk of epilepsy(1%), no adverse effects on
behavior/ neurocognition
Complex febrile convulsions:
Increased risk of epilepsy and this may also
be associated with other risk factors such as a
positive family history of epilepsy, an initial
febrile seizure before 9months of age, delayed
developmental milestones or a preexisting
neurological disorder.
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10. Coma : The patient cannot be aroused, and the eyes are closed
and do not open in response to any stimulation.
Maintaining alertness requires intact function of the cerebral
hemispheres and arousal mechanisms in reticular activating
system(RAS-also known as the ascending arousal system)- an
extensive network of nuclei and interconnecting fibers in
upper pons, mid brain and posterior diencephalon. Therefore,
the mechanism of impaired consciousness must involve both
cerebral hemispheres or dysfunction of the RAS
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11. To impair consciousness, cerebral dysfunction must be bilateral;
unilateral cerebral hemisphere disorders are not sufficient,
although they may cause severe neurologic deficits. However,
rarely, a unilateral massive hemispheric focal lesion(e.g left middle
cerebral artery stroke) impairs consciousness if the contralateral
hemisphere is already compromised or if it results in compression
of the contralateral hemisphere(such as by causing oedema.)
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12. Usually, RAS dysfunction results from a condition that has diffuse
effects such as toxic or metabolic disturbances (such as
hypoglycemia, hypoxia, uremia, drug overdose). It can also be
caused by focal ischemia(such as certain brainstem infarcts),
hemorrhage or direct mechanical disruption.
Any condition that increases the intracranial pressure may
decrease cerebral perfusion pressure, resulting in secondary brain
ischemia. Secondary brain ischemia may affect the RAS or both
cerebral hemispheres, impairing consciousness.
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13. a. Locked-in-syndrome: A rare neurological d/o in which there
is complete paralysis of all voluntary muscles except those
controlling eye movements
b. Hypersomnia such as Narcolepsy
c. Akinetic mutism: Syndrome characterized by marked
reduction of nearly all motor functions including facial
expression, gestures & speech output, but with some degree
of alertness (can be due to stroke)
d. Persistant vegetative state
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14. A. Infections: Meningitis, encephalitis, sepsis, CCM, CMV,
HSV, toxoplasmosis
B. Metabolic disorders: DKA, Hypoglycemia, hypothyroidism,
Electrolyte imbalances such as hypercalcemia.
C. Toxins
Intrinsic such as Urea due Kidney failure, NH4, CO2
Extrinsic such as Alcohol, CO, Drugs like opioids, anaesthetics,
sedatives
D. Traumatic: Head injury, Space occupying lesions (abscesses
, tumors)
E. Hypoxia
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19. o Onset of symptoms (gradual/acute)
o Any vision problems/dizziness/stupor/ numbness prior
o Any chronic disease such as DM, HTN
o History of seizures/ stroke
o Any chronic medications
o Hx of fever to rule out cerebral malaria
o Hx of yellowing eyes to rule out kernicterus
o Time of last meal to rule out hypoglycemia
o High pitched cry to rule out meningitis
o Hx of trauma to rule out TBI
o Hx of confusion to rule out electrolyte imbalances
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20. For a convulsing child, do a detailed general exam, and systemic
exams
a) General exams
Vitals: Temp, RR, SPO2, PR, GCS/BCS/AVPU
Note: BP & HR very crucial in syncopy
Febrile, jaundice, pallor, etc + pigmentation e.g in neuro-
cutaneous syndromes, etc
b) Systemic exams, e.g GIT, RS, CVS, and a Focused
Neurological Exam (Cranial nerves & Motor and Brainstem
reflexes e.g Corneal, Dolls reflex, oculovescular reflex)
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21. Absence of:
Pupils: no response to light
Cornea: no corneal reflexes
Oculocephalic testing (head turning) and oculovestibular
(caloric) testing
Motor response to adequate somatic stimulation within
distribution of cranial nerve
Gag reflex( pharyngeal and tracheal reflexes)
NB: Brainstem reflexes are usually used in assessing brainstem
death(if they are absent)
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22. Based on patient’s presentation.
Note: commonest cause of coma and convulsions in children is
Cerebral Malaria
Investigations include, but not limited to:
RBS
Blood smear for malaria/ mRDT
CSF Analysis/ culture, Blood culture, Serum electrolytes
EEG
Neuroimaging e.g CT/ MRI
CBC
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23. Random Blood Sugar.
Blood smear
Lumbar puncture for CSF analysis/ Blood culture
Metabolic screen
Imaging such as Cranial ultrasound on the anterior fontanelle,
CT scan.
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24. Seizures in children usually <3mins, however if
>5mins=Prolonged seizures, and these have more likelihood to
injure brain.
Status epilepticus is an Emergency
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25. - Ensure safety (patient and co.) space,remove tight clothes
- Left lateral (recovery)position
- ABC(Airway patency, Breathing, & Circulation)
AVOID
Restraining patient,
putting anything in the mouth, even feeds during an episode
Arousing convulsing child
Leaving convulsing pt unattended to before recovery
Time episodes where possible
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26. Initiate active pharmacological mgt
First line: Benzodiazepines (Diazepam/Midazolam) IV, or rectal.
IV Diazepam 0.3mg/kg (S.Es Resp arrest)
If 1st dose doesn’t work in 10 mins, give 2nd dose of diazepam.
If it doesn’t work, switch to 2nd line
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27. Second line:
These are longer acting anti-epileptics e.g Phenobarbital &
Phenytoin
Phenobarbital (10-15mg/kg slowly and monitor
vitals)
If this doesn’t work, inform ICU who’ll do general anaesthesia and
mechanical ventilation (3rd Line)
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28. Uganda Clinical Guidelines 2016
WHO Pocket handbook of paediatrics
ILAE
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