this is an the introduction part of coma which mainly involves the pathoophysiology,etiology and some description of coma like states.

2. objectives
Define coma and other disorders of
consciousness.
Identify common causes of coma.
Understand the pathophysiology of coma.
Identify clinical manifestations of a comatose
child.
Outline principles of management of coma in a
child.

3. Consciousness is a state of arousal(wakefulness)
with awareness of self and surroundings.
Arousal is mediated by
brainstem.
subcortical structure.
cerebral cortex(or at least part of it).

4. Awareness is primarily mediated by
cerebral cortex(but requires subcortical
connections).

5. Anatomic substance of
Consciousness
In general, the maintenance of
consciousness depends on interaction
between ARAS and the cerebral
hemispheres.

6. ARAS
It is a complex
polysynaptic fiber system
that extends from the
superior half of the pons
through the midbrain to
the posterior portion of
the hypothalamus and to
the thalamic reticular
formation.

7. Coma(Gr.deep sleep)
Coma is an alteration of consciousness
in which a child appears to be
asleep, cannot be aroused and shows
no awareness of the environment.
Coma is therefore the most profound
degree to which the two components of
consciousness , arousal and
awareness, can be diminished.

8. Cont…
Less profound states of consciousness
preserve one or more of these components
in some degree(lethargy, obtendation
, stupor…).

9. 1.Lethargy :
The patient is not fully alert,
Tends to drift to sleep when not stimulated,
 When aroused has appropriate response.
2.obtendation:
Difficult to arouse.
When aroused he/she is in a confusional state.
Usually constant stimulation is required to elicit
even marginal cooperation from the patient.

10. Cont…
3.stupor:
Respond only to persistent vigorous
stimulation(pain)
When aroused, is able only to groan or mumble.

11. Coma like states
Locked in syndrome
 A state of preserved
arousal and awareness.
 intact sleep/wake
cycles, and
 normal EEG activity with
 complete paralysis of the
voluntary motor systems
€ € € sparing the
midbrain or caused by
severe neuromus€ € € cular
disease

13. ???

14. Persistent Vegitative state
(apallic syndrome)
 Arousal is present but
awareness is absent.
 Sleep/wake cycles are present.
 € € € Movements are reflex and
are not purposeful or
repro€ € € ducible .
 The EEG generally
demonstrates diffuse slowing

16. Akinetic Mutism
 Arousal and awareness
are both present
 extreme € € € slowing or
absence of bodily
movement loss and
slowed cognition.
 Sleep/wake cycles are
present.
 The EEG demonstrates
diffuse € € € slowing.

17. Brain Death
 Permanent absence of all
brain activity, including
brainstem function.

18. from practical point of view
1,BRAIN DEATH = DEATH ?
2,DEATH=CARDIOPULMONARY DEATH ?
3,BRAIN DEATH =VEGITATIVE STATE ?

19. Causes of coma
1. Supratentorial lesions
2. Infratentorial lesions
3. Metabolic coma

20. Traumatic and nontraumatic causes of
coma have roughly equal annual
incidences.
Nontraumatic causes are more
frequent in infancy and early
childhood.

21. Infection is the most common nontraumatic
cause of coma( N. meningitides)
Indian study( M. tuberculosis)
An exogenous toxin (accidental and
deliberate intoxication) was the second
most common cause overall but was the
most common cause in adolescents .

22. A=APOPLEXY BRAIN STEM INFARCTION
INTRACRANIAL HEMORRHAGE
E=EPILEPSY POST-ICTAL OR INTE-ICTAL COMA
STATUS EPILEPTICUS
I=INJURY CONCUSSION
I=INFECTION MENINGOENCEPHALITIS
CEREBRAL ABSCESS
O=OPIATES STANDING FOR ALL CNS DEPRESSANT DRUGS
INCLUDING ALCOHOL
U=UREMIA STANDING FOR ALL METABOLIC CAUSES
A,E,I,O,U

23. summary
Coma is a state of “unarousable
unresponsiveness.”
It is a medical emergency.
Coma is a transient state. Patients either
recover, die, or evolve into a more permanent
state of impaired consciousness.
Nontraumatic causes are more frequent in
infancy and early childhood.
Of the nontraumatic causes infection is most

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dedication

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