1. Comatose child

2. Consciousness Confusion State of wakefulness with awareness of
self and surrounding .
Confusion
Altered consciousness (the subject misinterprets his surrounding) .

3. Delirium
state of high arousal ( acute confusion ) There is confusion and visual hallucination .
Stupor
Is abnormal sleepy stat from which the subject can be aroused by repeated stimuli .

4. What is a coma ?

5. Coma ( or unconsciousness )
Is a state in which a patient is totally unaware of both self and external surroundings.
Coma is not a disease. It is a symptom of disease or a response to an event.

6. Pathophysiology: A reduction in neuronal function resulting from disruption of cerebral cortical or brain stem integrity.

7. Causes

8. * Encephalopathy: * Infection: * Pressure effects: hypoxia ischemia
seizures and post ictal states
* Infection:
encephalitis
meningitis
septicemia
* Pressure effects:
cerebral edema
hydrocephalus
space occupying lesions

9. * Diseases of other systems:
* Vascular:
- hemorrhage :
extradural, subdural, subarachnoid, intraventricullar
- hypertensive encephalopathy
* Diseases of other systems:
- hepatic coma
- uremic encephalopathy
- respiratory failure with C02 narcosis
* Endocrine:
- adrenal insufficiency
- DKA / hypoglycemia
- hypothyroidism
- hypopituitarism

10. - H20, Na, K, Mg and Ca imbalance * Trauma.
* Exogenous intoxication:
- sedatives
- salicylates
- heavy metals
- carbon monoxide
* Fluid and acid-base balance:
- H20, Na, K, Mg and Ca imbalance
* Trauma.

11. How to approach to comatose patient ?

12. History Infection: Metabolic:
Fever, irritability, lethargy, poor feeding, rash, seizure.
Metabolic:
Hx of DM, hx of previous loss of consciousness, hepatomegaly, jaundice, oligurea, hypertension.

13. Poisoning:
Ask about drugs in the family, tablets, and alcohol.
Seizure:
Past hx of seizure, neurocutaneous lesions, developmental delay, abnormal eye movement, focal neurological signs.

14. Raised intracranial pressure:
Trauma:
Hx of road traffic accident, fall, bruising, hemorrhage, fractures.
Raised intracranial pressure:
Headache, vomiting,
focal neurological signs: ataxia, squint.
Papilloedema, retinal hemorrhage.

15. Physical Examination
General Examination
Neurological Examination

16. PULSE BLOOD PRESSURE In General Examination: Vital Signs:-
IRREGULAR – Cardiac diseases
ABSENT – Peripheral emboli
FEEBLE – Circulatory collapse
PULSE
BLOOD PRESSURE
- CVA
- hypertensive encephalopathy
- Cardiogenic shock
- Septicemia
- Addison’s disease

17. TEMPERATURE HYPOTHERMIA FEVER - Systemic infection : malaria
- Meningitis / encephalitis
- Heat stroke
- Drugs : Barbiturate
- Circulatory failure
- Myxoedema

18. Skin and mucous membranes:-
JAUNDICE
CYANOSIS
PURPURA
SKIN RASH 18

19. Head - scalp :- ENT :- Fundoscopy Neck - Cx. Spine:-
fractures, hematomas ,ant fontanels.
ENT :-
discharge, blood
Fundoscopy
Neck - Cx. Spine:-
fracture, neck stiffness, carotid pulses

20. Neurological examination
Determine level of consciousness by
GCS

21. * The Glasgow Coma Scale is used to determine the severity of a brain injury. It is often used at the emergency scene or emergency room.
* The scale is used as part of the initial evaluation of a patient, but does not assist in making the diagnosis the cause of coma
* Motor, verbal, and eye responses are rated.

22. 4 3 2 1
Spontaneous
To loud voice
To pain
None
Eye Opening

23. Verbal Response 5 4 3 2 1 smile, follows objects.
spontaneous irritable cry
Cries only to pain
Moans to pain
None
Oriented
disoriented and converses
inappropriate words
Incomprehensible sounds
Verbal Response

24. Motor Response 6 5 4 3 2 1 Obeys commands Localizes pain
Withdraws from pain
Abnormal flexion (decorticate posture)
AbnormalExtension (decerebrate posture)
None
Abnormal Extension (decerebrate posture)
Motor Response

25. GCS
Mild=13-15
Moderate=9-12
Severe=3-8
Minimum= Maximum=15

26. Core Neurological Exam (for coma);
1)Respiratory rate
2)Pupil
3)Extra ocular muscle, function muscle
4)Motor exam
5)Ciliospinal reflexes

27. METHODS OF ELICITING MOTOR RESPONSE
Supra-orbital nail-bed sternum 27

28. PUPILS – SIZE AND REACTION TO LIGHT
METABOLIC
Normal, reactive
DIENCEPHALIC
Small, reactive
MIDBRAIN
Large, fixed
PONS
pinpoint
III NERVE (UNCAL)
dilated, fixed 28

29. OCULAR-VESTIBULAR REFLEXES
OCULO-CEHPHALIC REFLEX (Doll’s eye movement)
When the head is turned to one side the eyes move to the opposite direction.
yes (brain stem intact)
no (brain stem damage) 29

30. PATTERN OF BREATHING
- Chyne-Stoke breathing (cerebral hemisphere lesion)
- Central Neurogenic Hyperventilation (midbrain)
- Apneustic breathing (pons)
- Ataxic breathing – gasping (medulla)

31. INVESTIGATION Drugs screen(eg_salicylates-
-diazepam-narcotics-amphetamines)
-Routine biochemistry (urea-electrolytes-glucose-calcium-liver biochemistry)
-Metabolic and endocrine studies (TSH-serum cortisol)
- Blood cultures
such as cerebral malaria(thick blood film)
-If the explanation remains unclear ,further investigation are needed .

32. IMAGING
CT or MRI brain imaging may indicate an otherwise unsuspected mass lesion or intracranial hemorrhage.

33. CSF examination
Lumber puncture should be performed in coma only after careful risk assessment .it is usually contraindicated when an intracranial mass lesion is a possibility .CT is necessary to exclude this. CSF examination is likely to alter therapy only if undiagnosed meningoencephalitis or other identifiable infection is present .

34. lumbar puncture….

35. Electroencephalography
EEG is of some value in the diagnosis of metabolic coma and encephalitis .

36. Management of comatose patient
Immediate Therapy Specific Therapy

37. IMMEDIATE MANAGEMENT C
IRCULATION A
IRWAY B
REATHING 37

38. GIVE 50% GLUCOSE 50ML INTRAVENOUSLY
IMMEDIATE MANAGEMENT
GIVE 50% GLUCOSE 50ML INTRAVENOUSLY
* THE RISK OF PERMANENT BRAIN DAMAGE IN THE HYPOGLYCEMIC PATIENT OUTWEIGHS THE
TEMPORARY WORSENING DUE TO INDUCED HYPERGLYCAEMIC STATE.
* ABSENCE OF HYPOGLYCAEMIA SYMPTOMS DOES NOT EXCLUDE HYPOGLYCAEMIA.
* HYPOGLYCAEMIA AT ‘NORMOGLYCAEMIC LEVEL’ IN DIABETIC PATIENTS. 38

39. Restore the hydration by IV fluids.
IMMEDIATE MANAGEMENT
Restore the hydration by IV fluids.
Treat the hyperthermia/ hypothermia
hyperthermia is more danger than hypothermia 39

40. TREAT RAISED INTRACRANIAL PRESSURE
SPECIFIC THERAPY
LOOK FOR ANY SEIZURE ACTIVITY (signs can be subtle like just twitching of mouth and eyes)
GIVE DIAZEPAM 10mg IV SLOWLY FOLLOWED BY PHENYTOIN 15mg/Kg 50mg/min
TREAT RAISED INTRACRANIAL PRESSURE
HYPERVENTILATION (PaCO mm. Hg) %MANNITOL (1.5 to 2.0G/Kg) FRUSEMIDE 40 to 120mg IV DEXAMETHASONE 12 to 18mg IV 40

41. IF SUSPECT MENINGITIS/ ENCEPHALITIS
SPECIFIC THERAPY
IF SUSPECT MENINGITIS/ ENCEPHALITIS
START ANTIBIOTICS (3rd generation cephalosporin) IV ACYCLOVIR IV 10mg/Kg. 8 hourly for HSE QUINIDINE IV for strong suspicion of cerebral malaria
RESTORE THE ACID-BASE BALANCE
METABOLIC ACIDOSIS – cardiac abnormality
METABOLIC ALKALOSIS – respiratory depression
RESPIRATORY ACIDOSIS - presages respiratory failure
RESPIRATORY ALKALOSIS – cardiac arrhythmias 41

42. SEMI-PRONE TRENDELERG –
ONE MOMENT PLEASE…
POSITION OF THE PATIENT
SEMI-PRONE TRENDELERG –
post-ictal state, drowning, metabolic causes
ELEVATION OF HEAD END TO 300 IN SUPINE
raised intracranial pressure due to any cause
ELEVATION OF THE LEG END
circulatory failure
CATHETER THE URINARY BLADDER 42