Approach to a Child with Coma
Prof Rashmi Kumar
Department of Pediatrics,
KG Medical University,
Lucknow
Coma: Definition
Derived from the Greek word Koma or
deep sleep
Various grades spectrum
State of altered consciousness with
reduced capacity for arousal and reduced
responsiveness to visual, auditory and
tactile stimulation
The word coma should be differentiated
from
Syncope (transient alteration of consciousness)
Seizure
Coma : Pathophysiology
Normal consciousness is maintained by integrity of
certain areas of the cerebral cortex, thalamus and
brain stem
Altered consciousness due to
Diffuse lesions of cerebral cortex (metabolic, toxic,
hypoxic)
Focal lesions of ARAS - central core of brain stem
Coma: Pathophysiology
Diffuse insult to both cerebral hemispheres
(metabolic/toxic/hypoxic/ischemic)
or
focal lesion affecting ascending reticular activating
system (ARAS) located in upper pons, midbrain &
diencephalon. Affected by compression (herniation)
Lesion in one cerebral hemisphere will not produce coma
ICT generalised ischemia (CPP=MAP-ICT)
focal ARAS damage by herniation
Coma: Pathophysiology
Diffuse bilateral cerebral Mass lesion compressing
lesion ARAS
Coma: Etiology
CNS Causes: Structural
CNS infections
Mass lesions CSF obstruction + volume
Trauma
Vascular
CNS Causes: Functional
Seizures
Hypoxic - ischemic injury
Coma: Etiology
Extracranial causes
Metabolic
Systemic shock hypoxia
hypo/ hypernatremia Reyes
hypoglycemia Respiratory failure
diabetic coma Acidosis/ alkalosis
hepatic Hyperosmolality
uremic Inherited metabolic
disorders
Coma: Etiology
Extracranial causes
Drugs
Barbiturates Iron
benzodiazepines Salicylates
opioids aceraminophen
tricyclics
Metals
antihistamines
Coma: Etiology
Extracranial causes
Toxic
Lead
gram negative endotoxemia
Shigella
CO poisoning
pesticides
alcohol/ ethylene glycol
Coma: Etiology
Extracranial causes
Endocrine
hypothyroidism
diabetic
Miscellaneous
hypertensive encephalopathy
heat stroke
hypothermia
Psychogenic
Coma: Immediate Management
Is resuscitation required?
A airway prevent tongue falling
back, suction
B breathingrespiratory support,
oxygen
C- circulationiv fluids, monitor BP,
vasopressors
If any evidence of poisoning GL
Coma : Quick History & Examn
Circumstances?
Duration & onset? Acute in CNS infection, trauma,
seizure, poisoning, metabolic, vascular
H/o poisoning?
H/o trauma?
H/o fever?
H/o seizure?
Past medical history
H/o seizures in the past?
H/o known endocrine disorder?
H/o headache/vomiting/visual symptoms?
Coma: Quick History & Examn
Vitals
Fever
BP
S/o shock
S/o ICP bradycardia, hypertension
Respiration rapid in acidosis & CNS lesions also
General Physical:
Evidence of trauma, injury, tongue bite
Jaundice
Breath - for odor of ketones, fetor hepaticus etc
Skin peticheae, exanthem
Dry, flushed skin in belladonna poisoning
Moist skin with salivation in organophosphorus poisoning
Complete systemic exam
Coma : Neurological Examn
Painful stimuli- strong pinch, pressure on nail bed, pressure on globe
Glasgow Coma Scale:
Best Motor Best Verbal Eye opening
1. none none none
2. extension to incomprehensible to pain
pain sounds
3. flexion to inappropriate to call
pain words
4. withdraws confused speech spontaneous
5. localises well oriented
6. Moves on
command
Coma : Neurological Examn
Modified Coma Scale for children < 2 yrs
Best Motor Best Verbal Eye opening
1. none none none
2. extension to moaning to to pain
pain pain
3. flexion to crying to to call
pain pain
4. withdraws irritable cry spontaneous
5. localises coos, babbles
6. Moves on
command
Coma : Neurological Examn
Meningeal signs
Tone/posturing
Decerebrate- lesion in upper pons
Decorticate- b/l cortical lesion with preservation of brain stem
function
Flaccidity when all cortical & brain stem function till
pontomedullary junction are lost
Fundus
Pupils
Pinpoint in pontine lesions/morphine poisoning
B/l fixed dilated in terminal state, severe ischemic damage,
atropine/belladonna poisoning
U/l unreactive pupil ? transtentorial herniation
Pupils generally small, equal & reactive in toxic/metabolic causes
Coma : Neurological Examn
Cranial nerves
6th nerve palsy false localizing sign
u/l 3rd impending herniation
Deficits suggest lesion in brain
S/o ICP
hypertension/bradycardia/abnormal breathing (Cheyne Stokes,
hyperventilation, apneustic, ataxic)
papilledema
posturing
cranial nerve palsies
Brain stem reflexes:
Dolls eye response
Oculovestibular reflex
Corneal reflex
Structural vs functional coma
Meningeal signs Absent
Focal deficits Absent
Brain stem reflexes Present
lost
Pupils unequal or Semidilated and
fixed dilated reactive
Coma: Investigations
Counts
Blood glucose, urea, electrolytes, acid base
Ammonia, liver function, lactate
Toxicology
Lumbar puncture CI if ICP. Abnormal in
CNS infections
Cultures
EEG usually non specific
Imaging r/o mass lesion
Coma: Treatment
Treat the cause
Supportive care antipyretics, anticonvulsants
Management of ICP
Mannitol 0.25 1 gm/kg of 20% solution (1.25 5 ml/kg) bolus iv
Frusemide
Diamox, glycerine
Steroids esp vasogenic edema
Hyperventilation lowers CBVCPP
Maintain PCO2 between 25 30 mm Hg
Nursing care:
Position
Nutrition
Care of eyes
Care of skin
Chest physiotherapy
Care of bowel & bladder
Physiotherapy
Persistent vegetative state:
patients after recovery from coma return to a
wakeful state without cognition/ awareness of
environment
Children who remain in this state for > 3
months do not regain functional skills
Causes
anoxia/ischemia/metabolic/encephalitic
coma/head trauma
Survival indefinite with good nursing care
Coma: Diagnosis of Brain Death
Importance
(American Academy of Neurology, 1995)
Prerequisites:
Cessation of all brain function
Proximate cause of brain death is known
Condition is irreversible
Cardinal features:
Coma
Absent brain stem reflexes
Pupillary light reflex
Corneal reflex
Oculocephalic
Oculovestibular
Oropharyngeal
Apnea
Confirmatory tests (optional)
Cerebral angiography
Electroencephalography
Radioisotope cerebral blood flow study
Transcranial Doppler ultrasonography
2 examinations interval depends
One/two physicians
Apnea Test
Prerequisites:- Core temperature > 36.5O C (97o F).
- Systolic blood pressure > 90 mm Hg (Adults only).
- Euvolemia (or positive fluid balance in the previous 6 hours).
- Normal PCO2 (or arterial PCO2 > 40 mm Hg).
- Normal PO2 (or preoxygenation to obtain arterial PO2 > 200 mm Hg).
Connect a pulse oximeter. Disconnect the ventilator or place the patient on CPAP at an
appropriate level or place a cannula at the level of the carina and administer 100% O2
endotracheally at 8L per minute.
Look closely for respiratory movements abdominal or chest excursions that produce
adequate tidal volumes).- Measure arterial PO2 , PCO2 , and pH after approximately 8
minutes (10 minutes for children). Resume mechanical ventilation.
Absence of spontaneous respiratory effort with PCO2 20 mm Hg > baseline (PCO2 > 60
mm Hg) confirms apnea and supports the diagnosis of death. If respiratory efforts are
present, the test is inconsistent with brain death and should be repeated. For children, if
the rise in PCO2 fails to reach 60 mm Hg, perform the test again for a duration of 15
minutes.- If the blood pressure becomes unstable or significant oxygen desaturation and
cardiac arrhythmias are present during testing, resume ventilation. Immediately draw an
arterial blood sample. If PCO2 > 60 mm Hg or the increase is 20 mm Hg > baseline
normalized PCO2, the apnea test is consistent with brain death. If not, the result is
indeterminate. A confirmatory test may be useful.
A. History: determine the cause of coma to eliminate remediable or reversible conditions
B. Physical examination criteria:
1. Coma and apnea
2. Absence of brain stem function
(a) Mid-position or fully dilated pupils
(b) Absence of spontaneous oculocephalic (doll's eye) and caloric-induced eye movements
(c) Absence of movement of bulbar musculature, corneal, gag, cough, sucking and rooting
reflexes
(d) Absence of respiratory effort with standardized testing for apnea
3. Patient must not be hypothermic or hypotensive
4. Flaccid tone and absence of spontaneous or induced movements excluding activity
mediated at spinal cord level
5. Examination should remain consistent for brain death throughout the predetermined period
of observation
Observation period according to age:
7 days to 2 months: Two examination and EEGs 48 hours apart
2 months to 1 year: Two examination and EEGs 24 hours apart or one
examination and an initial EEG showing ECS combined with a
radionuclide angiogram showing no CBF.
More than 1 year: Two examinations 12 to 24 hours apart; EEG and
isotope angiography are optional
(No criteria for neonates < 7days of age)
MCQ
1. Cerebral Perfusion Pressure equals:
a) Mean arterial pressure + intracranial pressure
b) Mean arterial pressure - intracranial pressure
c) Intracranial pressure Mean arterial pressure
d) None of the above
2. The following is true about Glasgow Coma Scale:
a) The highest score is 10
b) Lowest score is 3
c) There are 5 possible scores for Best Motor Response
d) Lowest score is 0
Unilateral unresponsive pupil is found in:
a) Morphine poisoning
b) Impending trantentorial herniation
c) Belladona poisoning
d) Brain death
A 7 year old child is brought to the emergency in coma. On
deep painful stimulus there is no verbal response, no eye
opening and slight extension of limbs. What is his
Glasgow Coma Score?
a) 7
b) 9
c) 5
d) 4
Signs of raised intracranial tension include all
except:
a) Hypertension
b) Shallow breathing
c) Bradycardia
d) Papilledema
Prerequisites for diagnosis of brain death
include all except:
a) Cessation of all brain function
b) Flat EEG
c) Proximate cause of coma is known
d) Condition is irreversible
