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Approach to a comatose child
- 2. objectives Define coma andother 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 astate 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 primarilymediated by cerebral cortex(but requires subcortical connections).
- 5. Anatomic substance of Consciousness Ingeneral, the maintenance of consciousness depends on interaction between ARAS and the cerebral hemispheres.
- 6. ARAS It is acomplex 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 isan 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 statesof consciousness preserve one or more of these components in some degree(lethargy, obtendation , stupor…).
- 9. 1.Lethargy : The patientis 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 topersistent vigorous stimulation(pain) When aroused, is able only to groan or mumble.
- 11. Coma like states Lockedin 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
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- 14. Persistent Vegitative state (apallicsyndrome) 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 Arousaland 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 Permanentabsence of all brain activity, including brainstem function.
- 18. from practical pointof 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 nontraumaticcauses of coma have roughly equal annual incidences. Nontraumatic causes are more frequent in infancy and early childhood.
- 21. Infection is themost 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 STEMINFARCTION 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 astate 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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