1. EVALUATION OF THE UNCONSCIOUS CHILD
DR. TA OGUNLESI (FWACP)

2. COMA COMA is a state of complete: absence of awareness of self
absence of purposeful responsiveness to the environment
absence of cognitive and mental functions.
DR. TA OGUNLESI (FWACP)

3. COMA
Consciousness depends on the interaction between the cerebral hemispheres and the Reticular Activating System (RAS), the arousal mechanism of the upper brain stem.
Altered sensorium results from either widespread cerebral disorder or destruction of the upper brainstem.
DR. TA OGUNLESI (FWACP)

4. GRADES OF ALTERED SENSORIUM
Drowsiness-patient is easily arousable.
Delirium-patient has extreme motor agitation and severe disorientation with delusions and hallucination.
Stupor-patient arousable only on vigorous external stimulation.
Semi-consciousness-patient responds to vigorous stimulation with reflex limb movement but without mental response.
Coma-patient is completely unarousable.
DR. TA OGUNLESI (FWACP)

5. AETIOLOGY OF COMA IN CHILDREN
Metabolic –more common in children (>50% of cases); gradual onset with slow progression and diffuse pattern of signs. The precise cause of coma is unclear but it is often due to cerebral oedema.
Structural- less common; sudden onset with rapid progression and focal distribution of signs.
Supratentorial
Infratentorial
Transtentorial
The cause of coma is usually due to compression or direct destruction of the cerebrum and herniation of the brainstem.
DR. TA OGUNLESI (FWACP)

6. ACUTE BRAIN INJURY
Alteration in sensorium usually results from acute brain injury which may be:
Traumatic (intracranial bleeding)
Infectious (meningitis/ encephalitis)
Metabolic (glucose, electrolyte derangements)
Hypoxic (status epilepticus, cardiac arrest)
DR. TA OGUNLESI (FWACP)

7. ACUTE BRAIN INJURY
These injuries secondarily cause cerebral oedema via alteration in the cerebral blood flow and perfusion.
↑Cerebral perfusion results in CEREBRAL OEDEMA formation which further worsens the elevated intracranial pressure.
Major risk of raised intracranial pressure is herniation of the brainstem into the foramen magnum (a.k.a coning)
DR. TA OGUNLESI (FWACP)

8. WHEN TO SUSPECT CEREBRAL OEDEMA
Gradual decline in consciousness
Unequal or fixed pupillary dilatation
Cushing’s Triad
Conjugate or disconjugate eye deviation
Development of decorticate or decerebrate rigidity
Note that the classical features of headache, effortless vomiting and blurred vision are only found in chronically elevated intracranial pressure.
DR. TA OGUNLESI (FWACP)

9. AETIOLOGY
Structural
Cerebral contusions or lacerations with hematomas,
Cerebral abscesses
Subdural effusions and empyema
Cerebrovascular diseases (AV malformations, aneurysms)
Cerebral tumours
Cerebral parasitic cysts (Cysticercosis; hydatidosis)
DR. TA OGUNLESI (FWACP)

10. AETIOLOGY Metabolic & Diffuse Hypoglycaemia Hyperbilirubinaemia
Hypothermia
Severe anaemia
Infections (Cerebral malaria, meningitis, encephalitis, cortical thrombophlebitis)
Hypoxic-ischaemic encephalopathy
Epilepsy
DKA
Alcohol intoxication
Hypertensive encephalopathy
Hepatic encephalopathy
Uraemic encephalopathy
Addison disease
Thyroid crisis
Reye syndrome
Amino-aciduria
Organic aciduria
DR. TA OGUNLESI (FWACP)

11. ASSESSMENT OF SENSORIUM
GLASGOW COMA SCALE/ SCORE
Applicable for children aged years
Maximum score = 15
Minimum score = 3
Coma = score <8
Best Eye Opening
Best Verbal Response
Best Motor Response
Spontaneous -4
Fully alert-5
Obeys command-6
To speech-3
Confused conversation-4
Localizes-5
To pain-2
Inappropriate words-3
Withdraws-4
No response-1
Incomprehensible sounds-2
Flexor posturing-3
Extensor posturing-2
DR. TA OGUNLESI (FWACP)

12. ASSESSMENT OF SENSORIUM
Best Eye Opening
Best Verbal Response
Best Motor Response
Spontaneous -4
Smiles & interacts-5
Spontaneous or obeys command-6
To speech-3
Consolable cry-4
Localizes-5
To pain-2
Persistently irritable-3
Withdraws-4
No response-1
Restless & Inconsolable cry-2
Flexor posturing-3
Extensor posturing-2
MODIFIED GLASGOW COMA SCALE/ SCORE
Applicable for children aged <4 years
Maximum score = 15
Minimum score = 3
Coma = score <8
DR. TA OGUNLESI (FWACP)

13. ASSESSMENT OF SENSORIUM
BLANTYRE COMA SCALE/ SCORE
Applicable for children who have not learnt to speak.
Maximum score = 5
Minimum score = 0
Coma = score <2
Best Eye Opening
Best Verbal Response
Best Motor Response
Directed
(eg towards mother’s face) -1
Appropriate cry-2
Localises well-2
Not directed-0
Moan or inappropriate cry -1
Withdraws from pain-1
None-0
Non-specific or total absence-0
DR. TA OGUNLESI (FWACP)

14. ASSESSMENT OF AN UNCONSCIOUS CHILD
OBJECTIVE-To minimise further brain injury
Ensure adequate resuscitation
Clear the airways
Secure the airways by positioning in the left lateral. Insertion of an oro-pharyngeal airway may be necessary.
Maintain circulation with the appropriate Intravenous Fluid (Normal Saline if shocked; Dopamine or dobutamine infusion may be necessary if in shock; dextrose-containing IVF in other cases).
DR. TA OGUNLESI (FWACP)

15. ASSESSMENT OF AN UNCONSCIOUS CHILD
Check RBS even if with Dextrostix & correct hypoglycaemia if present.
2. Brief history focused on:
Mode of onset of impaired sensorium
Course and duration of illness
Drug use history
DR. TA OGUNLESI (FWACP)

16. ASSESSMENT OF AN UNCONSCIOUS CHILD
3. Thorough physical examination focused on:
Assessment of sensorium using the Glasgow, Modified Glasgow or Blantyre scales.
Check for tense anterior fontanelle in infants; evidences of head injury: skull fracture or scalp lacerations.
Check the pupils for size, equality and reaction to light.
DR. TA OGUNLESI (FWACP)

17. ASSESSMENT OF AN UNCONSCIOUS CHILD
d. Check for meningeal irritation with Kernig or Brudzinski signs.
e. Examine the fundus for papilloedema (raised intra-cranial pressure) or choroidal tubercules (miliary TB).
f. Observe conjugate eye movements. Note the resting position of the eyes first and then briskly turn the head to either side to elicit the DOLL’S EYE MOVEMENT (OCULOCEPHALIC REFLEX).
DR. TA OGUNLESI (FWACP)

18. ASSESSMENT OF AN UNCONSCIOUS CHILD
Deviation of the eyes to the contralateral side suggests cortical or brain stem depression. This manoeuvre brings the eyes beyond the midline in cortical diseases but not in brainstem diseases.
Downward deviation of the eyes (setting sun appearance) suggest mid-brain compression
DR. TA OGUNLESI (FWACP)

19. ASSESSMENT OF AN UNCONSCIOUS CHILD
Assess the pulses and BP. Bradycardia and hypertension and apnoea (CUSHING’S TRIAD) suggest raised intra-cranial pressure but the triad is NOT always present.
DR. TA OGUNLESI (FWACP)

20. ASSESSMENT OF AN UNCONSCIOUS CHILD
Examine the cranial nerves (particularly squint for 3rd, 4th and 6th; corneal reflex for 5th; facial deviation for 7th)
Examine the nose and ears for CSF drainage in cases of skull basal fracture.
Examine the mouth: breath of alcohol, ketones, native herbs. Tongue laceration may indicate recent seizure.
DR. TA OGUNLESI (FWACP)

21. ASSESSMENT OF AN UNCONSCIOUS CHILD
Observe the posture (decorticate or decerebrate)
Examine the motor (bulk, tone, reflexes, power) and sensory functions (pain and superficial reflexes in particular).
Examine the skin and mucous membranes for palor, jaundice and uraemic frosts.
DR. TA OGUNLESI (FWACP)

22. RELEVANT LABORATORY INVESTIGATIONS
CT Scan/ MRI
Cerebral angiography/ Ventriculography
Electroencephalography (EEG)
Skull X-Ray
CBC including ESR
RBS
Serum Electrolytes & Urea
LFT
Lumbar Tap if meningitis is suspected and evidences of raised intracranial pressure are absent.
DR. TA OGUNLESI (FWACP)

23. CONTRAINDICATIONS TO LUMBAR TAP IN A COMATOSE PATIENT
Cardiopulmonary instability
Advanced brainstem dysfunction (eg. decerebrate posturing)
Gross skin sepsis over the spine
Evidence of Space-Occupying Lesion
DR. TA OGUNLESI (FWACP)

24. MANAGEMENT Treatment of specific aetiology Supportive management
Left-lateral positioning to prevent aspiration
Frequent oro-pharyngeal suctioning to prevent aspiration
DR. TA OGUNLESI (FWACP)

25. Endotracheal intubation if apnoea occurs
Maintenance of caloric and fluid intake via IVF, hyperalimentation or nasogastric intubation
Urethral catheterisation
Treatment of pressure areas to prevent decubitus ulcers
DR. TA OGUNLESI (FWACP)

26. MANAGEMENT 3. Treatment of cerebral oedema
Elevation of the head to 15 to 300 optimises the cerebral perfusion pressure
Control of fever prevents ↑ cerebral blood flow, cerebral perfusion and oedema. Antipyretics and muscular paralysis to prevent shivering may be helpful.
DR. TA OGUNLESI (FWACP)

27. Assisted Ventilation: To achieve hypocapnoea which causes cerebral vasoconstriction and reduces cerebral swelling.
Deliberate under-hydration (2/3 to ¾ of normal fluid requirement) has not been found to improve outcome because it further reduces resultant CPP.
DR. TA OGUNLESI (FWACP)

28. MANAGEMENT
Control of seizures with anticonvulsants (seizures increases the metabolism of brain tissue and ↑ the risk of oedema).
Mannitol is used when herniation is imminent. Given as 0.5-1g/kg by rapid IV infusion over 20 minutes. Causes osmotic diuresis. May be repeated in 4 hours.
Corticosteroids (Dexamethazone 0.2mg/kg/day iv or im) are useful only in vasogenic cerebral oedema (found in cases of CNS infections, abscesses and tumours).
DR. TA OGUNLESI (FWACP)