Very practical way of approaching to a child with altered sensorium in the setting of EMD or in PICU

1. Approach
To a child
With
Altered Sensorium
Dr.G.Sudhakar M.D(peds);D.C.H;
Professor Of Pediatrics(Rtrd)
Consultant Pediatrician
KIMS Hospitals
Kurnool

2. Objectives
• Familiarize ourselves with COMA and related terms
• Pathophysiology of coma
• Approach to assessment
• Approach to investigations
• Approach to treatment
• Aggravating issues , how to deal with?
• Goals of treatment
• Prognosis

3. Various terms of Altered sensorium
• Consciousness (Intact arousal… ARAS and intact Awareness… cerebral cortex)
… both cortex, ARAS and brainstem intact
• Lethargy, obtundation, stupor ( sleepy , awareness is less severely impaired ) …
cortex < ARAS impaired… brainstem intact
• Delirium (hyperactive & hypoactive) looks awake but completely unaware of
surroundings… cortex > ARAS impaired, brain stem intact
• Coma ( Awakeness and Awareness … both are lost) cortex, ARAS grossly
impaired, Brain stem intact
• Awakeness and Awareness are affected to varied levels in these clinical
situations and all the terms mean Altered Sensorium/Altered mental status
only and hence no need to differentiate practically.
• May recover, may die, progress to Brain death, transforms into MCS, PVS )
• Brain death ... classic triad of Coma, Apnea and absent brainstem reflexes
• MCS…as sequalae ( intact brain stem & minimal response is elicitable to a
stimulus)
• PVS …as sequalae ( intact brain stem & no response to any stimuli )

4. Rule-out Coma mimics
• Complete paralysis / Locked in syndrome
• Akinetic mutism / Abulia
• Catatonia and psychiatric unresponsive ness

5. Anatomy of COMA ( Encephalopathy)
and pathophysiology
• Toxic
encephalo
pathy
• Epileptic
encephalo
pathy
• Metabolic
encephalo
pathy
• Organic/
structural
encephalo
pathy Cerebral
cell ,
ARAS,
inter
connect
Cell
environ
Toxics
Genetic
abnorm
al cell

6. Likely issues with altered sensorium
• 1.Postural tone is lost… falls…injuries? Scene safety?
• 2.Loss of communication… Rescuers help?
• 3.Loss of oropharyngeal and glosso - pharyngeal muscle
tone… tongue falls back into throat causing UAO…
• 4.Loss of protective throat reflexes … pooling of saliva (0.5-
1ml/kg/hour) in throat and subsequent Aspiration…
• 5.Autonomic instability… loss of balance between sympathetic
and parasympathetic functions… vasomotor centre instability
and poor response to vasoactive agents
• 6.Vital centers affected… loss of cardiorespiratory drive.

7. A 3 yrs old Irfan is rushed into PEMD?
Mother on the way to hospital.
• Initial impression ( visual and auditory clues )
• Appearance : Hypo/ Hypertonic, no interaction, no cry, no
looks/gaze, no speech
• Breathing : Normal, shallow, RD, noises with breathing(
gurgling ), no breathing
• Color : pale, bleeds, skin spots, flushed, mottled etc…
• Any one abnormality in any sphere is a sign of life-threatening
problem .

8. Life-threatening problem.
What to do now?
Continue Assessment or Intervene?
• For any suspected life-threatening problem
• EAI cycle to be followed
• Examined ABC
• Assessed as Life threatening problem
• Intervene now?
Examine
Assess
intervene

9. Stabilize ABC
• Airway : positioning, cleared the airway, and secure the
airway with non-invasive ( if maintainable) or invasive
measures ( if not maintainable) Intubated (RSI)
• Breathing : supplemental oxygen if spontaneous
breathing is adequate, and Assisted breathing if
spontaneous breathing is inadequate.( connected to
ventilator)
• Circulation : Gain IV/IO access, obtain blood sample for
Lab, finger prick Glucose ( 50mg% … so corrected with
0.5ml/kg of 10%D ), connected to cardiac monitor, if
needed fluid boluses, vasoactive infusions.

10. What to do after initial stabilization?
“Classify the physiological status”
by
• Primary assessment : To know
Respiratory status
Circulatory status
Neurological status

11. Primary assessment
(ABCDE approach)
• 1.Airway : already taken care of
• 2.Breathing : already taken care of
• 3.Circulation: PR 134bpm, PV normal, CRT 3sec,
peripheries warm, temp 39 degrees C. BP 96/54mm
of Hg, MAP of 68mm of Hg
• 4.Diisability : U/AVPU, GCS 7, tone increased, PCD of
both eyeballs upwards and to right, OCR intact,
pupils are small and reactive.
• 5.Exposure : undressed, temp 39 degrees C.

12. At the end of Primary Assessment
• Respiratory status : intubated and secured
• Circulatory status : Stable ( no signs of shock)
• Neurological Status : Coma ( GCS 7) with active focal
seizures.
• Treat active seizures : Benzodiazepines followed by
phenytoin as per status- epilepticus protocol
• Treat fever ( paracetamol rectal suppository )
• Until now we assessed and performed some clues-
based interventions as needed.
• Watch for Raised ICP in every child with altered
sensorium and GCS score of <12.
• GCS of 12 or <12, is a neuro emergency and raised
ICP very likely?

15. Raised ICP( >20mm of Hg)
(ICP 2-5 in infants, 3-7 young children, 10-15 older children)
• Clinical
• Imaging
CT Midline shift
Effaced basal cisterns
Effaced sulci
Thumb printing
Optic sheath diameter
Ocular US
<1 year 5.2mm
> 1 year 5.8mm
• Direct measure EVD / Intra cerebral cath
• >20mm of Hg
• >5 minutes is persistent

16. Managing raised ICP
• Measures in ER/PICU
Rapid correction of
Hypoxia
Hypercarbia and
Hypotension (CPP= MAP-ICP)
( MAP = CPP + ICP )
<5years 40-50mm of Hg and
>5 years 50-60 of mm-6Hg.
MAP of 60-70mm of Hg in <5yrs
. 70-80mm of Hg in >5yrs
( Fluids & vasoconstrictors)
General measures
Head end elevation to 15-30
degrees
Head in midline
Normal Temp, Glucose,
Thiamine (MVI) in SAM
Hb >7gm%
Prophylactic AED
Control pain and agitation
General Nursing measures
Nutrition, fluids and electrolyte
disturbances
Avoid vasodilators, Ketamine,
5%D, Propofol

18. 160

19. ( Never )

20. ( + osmotic agents )

22. To know the cause of altered sensorium
Get clues from History and physical examination
• Secondary assessment : SAMPLE history and Focused
Head to Toe physical examination (Fever + 2days,
irritable 1day, had one FS at 18months of age.)
• Focused neuro and clues-based physical examination
GCS trends
Brainstem reflexes
Motor responses
Head to toe screen

23. Clues from History
• Recurrence, vomiting and FTT s/o Metabolic
• Jaundice, melena s/o Hepatic encephalopathy
• Edema, oliguria s/o Hypertensive encephalopathy or uremic
encephalopathy
• vomiting, loose stools s/o HUS, hypovolemia.
• Birth anoxia, Developmental delay s/o seizures.
• Endemicity, epidemics s/o AES.
• H/o preceding VE s/o ADEM
• Family h/o open TB or epilepsy
• H/o immune compromised state s/o TBM, HIV, opportunistic
infections
• Response to Thiamin, Glucose and calcium

24. Clues from physical examination
• Repetitive multifocal myoclonic jerks s/o Metabolic,
Anoxic and Toxic encephalopathies
• FND s/o focal lesions
• Flaccidity s/o loss of cortical and brainstem functions
• Decorticate and decerebrate posturing s/o bilateral
cortical and midbrain lesions.
• Mild altered sensorium with asterixis, no FND and intact
brain stem reflexes often s/o Metabolic encephalopathy
• Loss of brain stem reflexes s/o Brain death
• Papilledema s/o raised ICP or Hypertension
• Choroid tubercles s/o TBM
• Retinal bleeds in AES s/o JE and poor prognosis

25. Diagnostic investigations
• Must for all :
• General : CBC, UA, SGOT and SGPT, urea and creatinine,
cultures of blood and urine
• Organic : Neuro-imaging, LP
• Metabolic : ABG, Lactate, Electrolytes, Ca, Mg, Glucose
• Toxic : Toxic screening ( blood and Urine )
• Epileptic : EEG monitoring

26. What are clues-based investigations ?
• Metabolic profile if persistent acidosis with increased anion
gap
• Serum Ammonia
• Specific drug profiles if suspicious
• Pseudo-cholinesterase levels if OPC poisoning is suspected
but history is unyielding
• Coagulation profile if IC bleeds
• CTD profile if SID/AID/vasculitis is a clinical possibility
• Repeat tests as need based

31. Consultations …
• Be in continuous touch and in coordination with your
Pediatric intensivist
• Neurologist consultation for persistent altered
sensorium or if fresh neurological signs appearing
• Nephrology services for MODS involving kidney
• NS consultation for any SOL
• Endocrinologist services may be sought as needed
• General pediatrician should take a central leadership
role and coordinate services of required

32. Goals of interventions
• Saving life of the child.
• Intact neurological survival
• Measures to prevent recurrence.

33. Diagnostic Algorithm
Altered sensorium
Initial Impression & Primary assessment
Stabilize ABC,
Glucose , Thiamin
Secondary assessment & Diagnostic testing
Infective Non-Infective
CBC, LP, CT/MRI, ABG,
Electrolytes, EEG
CT/MRI, ABG, Ammonia,
Clues based tests, CSF
AES
+/- Metabolic issues
( hypo/hyper natremia
Hypo calcemic, hypo magnesia,
hypoxia, hypercarbia,
Cytokine storm etc.)
+/- structural issues on imaging
(disease specific findings,
Complications, unrelated focal lesions, ADEM)
+/- NCSE
Structural
Neoplasms, AVM, ICH,
genetic, calcifications, etc.
Metabolic
IEM, hepatic, uremic etc.
Toxic
OPC, Drugs, Lead etc.
Epileptic
Genetic, secondary
Vasculitis

34. Causes of altered sensorium
• Infections : Pyogenic meningitis
AES, ADEM, cerebral malaria
Rickettsia, Lyme disease,
Brain abscess, subdural empyema
Sepsis
• Toxidromes : OPC
Kerosene
Drugs
Lead
AED

35. Causes contnd…
• Metabolic disturbances :
Hypoglycemia, DKA
Dyselectrolytemia
Uremic, Hepatic encephalopathy
IEM
• Endocrinal :
Adrenal insufficiency
Hypoparathyroidism
Thyroid disorders

36. Causes contnd…
• Head injury (TBI) : Concussion, contusion,
Diffuse Axonal Injury
ICH ( EDH, SDH, ICH, SAH )
• Epileptic : Post ictal, SE
• Increased ICP : ICSOL, Brain abscess
Hydrocephalus, ICH.
• Reyes syndrome

37. Causes contnd…
• Vascular : CVT, AVM, ICH
Emboli
Vasculitis
• Hypertensive encephalopathy
• Hypoxic ischemic injury : Hypotension, cardiac arrest, cardiac
arrhythmias, near drowning
• Psycho-social : CA&N (NAT)

38. Summary of
Managing a comatose child
• Airway
• Breathing
• Circulation
• Glucose, calcium, MVI
• Raised ICP
• Seizures
• General Nursing Care
• Multi disciplinary
coordination
• Infection
• Temperature control
• Acid base status
• Fluids, Electrolyte
disturbances and
Nutrition
• Antidotes
• Agitation

39. Prognosis
• COMA can last for 2-4 weeks
• Good prognosis in Toxidromes
• Worst prognosis with Hypoxic Ischemic Injury
• Variable with Infective
• Variable with TBI
• GCS- lower the score worse the prognosis
• Quality of supportive and Nursing care matters
between life and death

40. Thank you