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Pediatric Coma

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Pediatric Coma
Introduction
Disorders of Consciousness
Coma Mimics
Etiologies
Evaluation
Brainstem Reflexes
Pediatric Glasgow Coma Scale
Management
Coma Sequelae

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Pediatric Coma

  1. 1. bbyy SShhaannyyaarr QQaaddiirr Shanyar.com
  2. 2. Introduction  2 of 19  From the Greek koma, meaning "deep sleep"  It is an alteration of consciousness in which a person appears to be asleep, cannot be aroused even by painful stimuli, and shows no awareness of the environment  Acute life-threatening neurological emergency  Requires prompt intervention for preservation of life & brain function
  3. 3. Disorders of Consciousness  3 of 19  Lethargy: difficulty maintaining an aroused state, can be aroused with little difficulty  Obtundation: decreased arousal but responsive to stimuli, cannot fully be aroused  Stupor: responsiveness to pain but not to other stimuli  Coma: unresponsive even to painful stimuli
  4. 4. Coma mimics  4 of 19  Complete paralysis: locked-in state, GBS, botulism  Akinetic-mutism: frontal lobe lesions, tone & reflexes intact  Catatonia
  5. 5. Etiology  5 of 19  Consciousness can be diminished or abolished by  Dysfunction within the brainstem  Impairment of both cerebral hemispheres  Insults that globally depress neuronal activity (e.g. metabolic disturbances)  Unilateral cerebral lesions may cause coma if they compress or injure contralateral or brainstem structures.
  6. 6. Etiologies-1  6 of 19  Infection  Meningitis  Encephalitis  Brain abscess  Trauma  Shaken baby syndrome  Intracerebral hemorrhage  Concussion  Toxins  Narcotics  Antihistamines  Anticonvulsants  Hypoxia-ischemia  Near-drowning  Cardiac arrhythmia  Carbon monoxide intoxication  Strangulation
  7. 7. Etiologies-2  7 of 19  Epilepsy  Subclinical status epilepticus  Postictal states  Stroke  Arterial ischemic stroke  Cerebral sinovenous thrombosis  Hemorrhage  Metabolic derangements  Hypoglycemia  Hyponatremia or its correction  Hypernatremia or its correction  Hyperosmolality or its correction  Hypercapnia
  8. 8. Evaluation   Vital signs and general and trauma examination  Neurologic examination and GCS  Screening laboratories (CBC, glucose, electrolytes, BUN, creatinine, blood 8 of 19 cultures, LFTs, urinalysis, urine drug screen)  Head CT scan: do emergently if focal neurologic signs, papilledema, fever - consider rapid MRI instead if available.  Lumbar puncture: do emergently after CT scan if fever, elevated WBC, meningismus; otherwise do according to level of suspicion for diagnosis or if cause remains obscure  Other laboratory tests: for metabolic conditions, coagulation tests, carboxyhemoglobin, specific drug concentrations - do according to level of suspicion for diagnosis or if cause remains obscure  EEG: for possible nonconvulsive seizure, or if diagnosis remains obscure  Brain MRI with DWI, if cause remains obscure
  9. 9. Pupillary reflex  9 of 19 Size Possible interpretation Normal eye with two pupils equal in size and reactive to light. This means that the patient is probably not in a coma and is probably lethargic, under influence of a drug, or sleeping. Pinpoint pupils: opiate overdose, damage to pons. The pinpoint pupils are still reactive to light, bilaterally. One pupil is dilated and unreactive, while the other is normal. Damage to the oculomotor nerve or possibility of vascular involvement. Both pupils are dilated and unreactive to light. This could be due to overdose of certain medications, hypothermia or severe anoxia.
  10. 10. 10 of 19
  11. 11. 11 of 19 Pediatric GCS Sign Pediatric GCS Score Eye opening Spontaneous 4 To sound 3 To pain 2 None 1 Verbal response Smile, orientation to sound, interacts, follows objects 5 Cries, irritable 4 Cries to pain 3 Moans to pain 2 None 1 Motor response Spontaneous movements (obeys command) 6 Withdraws to touch (localizes pain) 5 Withdraws to pain 4 Abnormal flexion to pain (decorticate) 3 Abnormal extension to pain (decerebrate) 2 None 1
  12. 12. 12 of 19
  13. 13. Management-1  13 of 19  ABCs:  Intubate if GCS ≤8 or respiratory failure  Stabilize cervical spine  Supplement O2  IV access  Blood pressure support as needed  Dextrose 0.25 g/kg (2.5 mL/kg of 10 % dextrose solution)  Treat definite seizures. Lorazepam (0.1 mg/kg, maximum single dose 5 mg). If seizures continue treat as for status epilepticus.
  14. 14. Management-2  14 of 19  Infection:  Ceftriaxone 100 mg/kg (maximum single dose 2 grams) and Vancomycin  Acyclovir  Ingestion:  Naloxone 0.1 mg/kg IV; maximum 2 mg IV (use if opioid toxidrome: miosis, respiratory depression, hypotonia)  Increased ICP:  Mannitol 0.5 - 1 gram/kg IV
  15. 15. Prognosis  15 of 19  Largely specific to the etiology  Mortality rates according to a study in England:  near-drowning - 84%  infection - 60%  metabolic causes 27%  intoxication - 3.4%
  16. 16.  16 of 19 Coma Sequelae  Coma is transient, patients either recover, die or go into a more permanent state of impaired consciousness  Persistent vegetative state (PVS): permanent if lasts > 12 mo after traumatic injury or > 3 mo after non-traumatic injury  Minimally conscious state: severe alteration in consciousness who do not meet criteria for PVS  Brain death: coma, apnea, and absent brainstem reflexes. No chance of recovery, synonymous with death in most countries
  17. 17. Persistent Vegetative State (PVS)  17 of 19  No evidence of awareness of self or environment and no ability to interact with others.  No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli.  No evidence of language comprehension or expression.  Intermittent wakefulness manifested by the presence of sleep-wake cycles.  Sufficiently preserved hypothalamic and brainstem autonomic function to permit survival with medical and nursing care.  Bowel and bladder incontinence.  Variably preserved cranial nerve reflexes and spinal reflexes.
  18. 18.  18 of 19 Thank You!
  19. 19. References  19 of 19 1. Nelson Essentials of Pediatrics, 7e – 2015 2. The Harriet Lane Handbook, 20e - 2015 3. Plum & Posner's Diagnosis of Stupor & Coma, 4e – 2007 4. Evaluation of stupor & coma in children. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2013. 5. Coma on Wikipedia (http://en.wikipedia.org/wiki/Coma)

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