Approach to a child with coma

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Approach to a child with coma:

Approach to a child with coma Dr Sujata S Alawani Dr Chintan

Outline :

Outline States of altered consciousness Glasgow Coma Scale Pathophysiology Causes

What is consciousness?:

What is consciousness? “State of wakefulness and awareness of self and surroundings” (Abend et al., Rogers’ Handbook of Pediatric Intensive Care Medicine, 2009, p. 256) A conscious individual is: Aware of himself and environment, Capable of responding correctly to verbal and mechanical stimuli and Able to recall past events. Two neurophysiologic functions: Arousal Awareness

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Alert: Fully conscious Lethargic: appear somnolent, but may be able to maintain arousal Obtunded: requires touch or voice to maintain arousal Stuporous: unresponsiveness from which the individual can be aroused only by painful stimulus Comatose: State in which the patient is unable to arouse or respond to noxious stimuli and is completely unaware of self and surroundings Levels of Consciousness:

Delirium:

Delirium Delirium is a heightened mental state, characterized by disorientation, irritability, fearful responses, and sensory misperception. Hallucinations, usually visual, as well as delusions may occur.

Confusion:

Confusion Confusion is a state of impaired ability to think and reason clearly, resulting in difficulty with orientation, simple cognitive processing, and acquisition of new memory. Confusion may occur in a depressed or activated mental state.

Pathophysiology:

Pathophysiology Both wakefulness (arousal) and awareness are fundamental to maintain consciousness.

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The awake state requires the integrity of the reticular activating system (RAS), located in the upper brainstem and thalamus. The regions of the reticular formation extend from the rostral brainstem (midbrain and upper pontine tegmentum) to the lower thalamus (Moruzzi & Magoun 1949). The hypothalamus is also important for consciousness

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Awareness,a higher cognitive function, is the combination of cognition and affect and is determined by the cerebral hemispheres.

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Integral consciousness requires an Intact RAS, Cerebral hemispheres and Healthy projections between the two systems.

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A The child is awake, alert, and interactive with parents and care providers V The child responds only if the care provider or parents call the child's name or speak loudly P The child responds only to painful stimuli, such as pinching the nail bed of a toe or finger U The child is unresponsive to all stimuli From Ralston M, Hazinski MF, Zaritsky AL, et al, editors: PALS course guide and PALS provider manual: Dallas, 2007, American Heart Association. AVPU NEUROLOGIC ASSESSMENT

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Unconsciousness may be physiologic during sleep: a stimulus returns the person to normal consciousness

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Coma and other alterations of consciousness result from three primary causes, occurring separately or in combination: (a) diffuse or multifocal bilateral cerebral dysfunction, (b) substantial damage to the RAS, or (c) impaired communication between these two regions

Assessment of the state of consciousness::

Assessment of the state of consciousness: The state of consciousness can be assessed by Glasgow coma scale. The Glasgow coma scale is a useful tool for the grading of the degree of altered consciousness and the severity of CNS insult. Glasgow coma scale is used for adults and older children and its modification is used in infants and young children. The scale is simple, easy, can be applied at bed side and does not need any investigations

Glasgow Coma Scale ( GCS ):

Glasgow Coma Scale ( GCS ) ACTIVITY BEST RESPONSE ( to verbal or mechanical stimuli ) Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE ( to verbal or mechanical stimuli ) Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE ( to verbal or mechanical stimuli ) Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE ( to verbal or mechanical stimuli ) Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech or sound To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech or sound To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech or sound To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech or sound To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech or sound To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech or sound To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech or sound To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Painful Stimuli::

Painful Stimuli:

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Decorticate posture characterized by bilateral : Flexion at elbow and wrist Shoulder adduction and Legs extension – plantar flexion Glasgow Coma Scale ( GCS )

Glasgow Coma Scale ( GCS ):

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Glasgow Coma Scale ( GCS )

PowerPoint Presentation:

ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1 Decerebrate posture characterized by bilateral : Extension at elbow and wrist flexion Shoulder adduction and Legs extension – plantar flexion

Glasgow Coma Scale ( GCS ):

Glasgow Coma Scale ( GCS ) ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1

Glasgow Coma Scale ( GCS ):

Glasgow Coma Scale ( GCS ) ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1

Glasgow Coma Scale ( GCS ):

Glasgow Coma Scale ( GCS ) ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to touch Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1

Glasgow Coma Scale ( GCS ):

Glasgow Coma Scale ( GCS ) ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1

Glasgow Coma Scale ( GCS ):

Glasgow Coma Scale ( GCS ) ACTIVITY BEST RESPONSE Adults/Older Children Infants ( modified GCS ) Score Eye Opening ( E ) Spontaneous To speech To pain None Spontaneous To speech To pain None 4 3 2 1 Verbal ( V ) Appropriate speech Confused speech Inappropriate words Incomprehensible or none specific sounds None Coos, babbles Irritable, cries Cries to pain Moans to pain None 5 4 3 2 1 Motor ( M ) Obeys commands Localizes pain Withdraws to pain Decorticate to pain Decerebrate to pain None Normal spontaneous movement Withdraws to touch Withdraws to pain Decorticate to pain Decerebrate to pain None 6 5 4 3 2 1

Significance of Glasgow coma scores::

Significance of Glasgow coma scores: (1) Diagnosis of different grades of altered consciousness: Fully conscious child or infant is given GCS of 15. Mild to moderate grades of altered consciousness (disturbed consciousness but, not unconscious ) are given GCS from 14 – 11 as with lethargy, confusion and delirium .

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Severe grades as with stupor ( unconscious, partially responsive ) are given GCS from 9 – 10.

Significance of Glasgow coma scores::

Significance of Glasgow coma scores: (1) Diagnosis of different grades of altered consciousness: As coma is defined as: No eye opening (score 1), No recognizable words uttered (score 2 ), Not obeying commands (score 5), and So the sum of G.C.S. = 8 . So, patients whose score = 8 or less are in coma. The lower the score the deeper is the coma.

Significance of Glasgow coma scores::

Significance of Glasgow coma scores: (2) Follow – up of comatose children: Glasgow coma scores helps in follow-up of patients and in assessment of response to therapy.

PowerPoint Presentation:

A Glasgow Coma Scale for a child. A score of 3 to 8 denotes severe trauma, 9 to 12 moderate trauma, and 13 to 15 slight trauma. Notice the gradual improvement from coma in this example.

Significance of Glasgow coma scores::

Significance of Glasgow coma scores : (3) Prediction of prognosis of comatose child: GCS ≤ 5 on admission, the probability of death is 90%, GCS ≥ 10, the probability of death is decreasing to 1%

The CHOP infant coma scale (infant face scale):

The CHOP infant coma scale (infant face scale) Developed for children younger than 2 years of age (Durham et al. 2000) Also referred to as the Infant Face Scale (IFS), since it relies on the infant’s crying and facial expressions. It differs from other scales by reliance on objective behavioral observations and assesses cortical and brainstem function It parallels the GCS in scoring Based on infant behaviors and can be applied to the intubated child.

The CHOP infant coma scale (infant face scale):

The CHOP infant coma scale (infant face scale) Eye opening Spontaneous 4 Verbal stimulation to touch 3 Painful stimulation 2 None 1 Motor Spontaneous normal movements 6 Spontaneous normal movements, reduced in frequency or excursion; hypoactive 5 Nonspecific movement to deep pain only (trapezius pinch) 4 Abnormal rhythmic spontaneous movements: seizure-like activity 3 Extension, either spontaneous, or to painful stimuli 2 Flaccid 1

PowerPoint Presentation:

Verbal/face Cries spontaneously or with handling, or to minor pain, alternating with periods of quiet wakefulness 5 Cries spontaneously, or with handling, or to minor pain,alternating with sleep only 4 Cries to deep pain only (trapezius pinch) 3 Grimaces only to pain 2 No facial expression to pain 1

Causes of Coma:

Causes of Coma T Trauma, head injury Shaken baby syndrome: non-specific history, retinal hemorrhages. I Intussusception Mental status changes may precede abdominal finding Insulin, Hypoglycemia Inborn errors of metabolism P Psychogenic Common in adolescents S Seizures Postictal states, non-convulsive status may masquerade as undifferentiated coma. Shock, stroke Coma secondary to poor brain perfusion, arterial and venous infarcts Shunt Blocked or infected ventriculo-peritoneal shunts

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A Alcohol ingestion, abuse E Electrolytes Disturbances of sodium, calcium, magnesium Encephalopathy Hypertensive, Reye syndrome, hepatic failure, urea cycle defects, lead encephalopathy I Infections Encephalitis, meningitis, malaria O Overdose, ingestion Consider with unexplained loss of consciousness U Uremic encephalopathy

Important causes of coma in Indian children:

Important causes of coma in Indian children Bacterial, tuberculous and viral meningoencephalitis Malaria Non-infectious causes including stroke, ingestions and Reye syndrome

Etiologic Classification Of Coma :

Etiologic Classification Of Coma

Etiologic Classification Of Coma :

Etiologic Classification Of Coma I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma Local CNS causes : 1. Head trauma may produce: Cerebral contusion. Cerebral laceration. Cerebral edema. Epidural and subdural hematoma. I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

PowerPoint Presentation:

Triad of subdural hematoma , retinal hemorrhage , and cerebral edema which usually, consistent with current medical understanding, infer child abuse caused by intentional shaking. In a majority of cases there is no visible sign of external trauma. SBS is often fatal and can cause severe brain damage , resulting in lifelong disability Usually occur in children younger than 2 years old but may be seen in children up to the age of 5.

PowerPoint Presentation:

Estimated mortality - 15% to 38% Up to half of deaths related to child abuse are reportedly due to shaken baby syndrome Nonfatal consequences of SBS include varying degrees of visual impairment, motor impairment and cognitive impairment Medico-legal issue

Shaken Baby Syndrome:

Shaken Baby Syndrome

PowerPoint Presentation:

Subdural Hematoma

PowerPoint Presentation:

Acute epidural hematoma and midline shift

Etiologic Classification Of Coma :

Etiologic Classification Of Coma Local CNS causes : 2. Vascular : Hemorrhage, Thrombosis, and Embolism. I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma Local CNS causes : 2. Vascular : Hemorrhage, Thrombosis, and Embolism. 3. Epilepsy (Post-convulsion coma). I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma Local CNS causes : D. Central nervous system infections : Meningitis. Encephalitis. Brain abscess. Cerebral malaria. I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma Local CNS causes : D. Central nervous system infections : Meningitis. Encephalitis. Brain abscess. Cerebral malaria. F. Brain tumors . I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

PowerPoint Presentation:

Cerebral Abscess

Etiologic Classification Of Coma :

Etiologic Classification Of Coma II. Systemic causes: I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma II. Systemic causes: 1- Metabolic disorders : Diabetic ketoacidosis. Hypoglycemia : insulin overdosage in diabetic patients. Hypoxemia : Congestive heart failure - acute respiratory failure and carbon monoxide poisoning. Hypernatremia and hyponatremia. I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma II. Systemic causes: I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma II. Systemic causes: 2-Renal failure. I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma II. Systemic causes: 2-Renal failure. 3-Hepatic failure . I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma II. Systemic causes: 2-Renal failure. 3-Hepatic failure . 4-Severe systemic sepsis . I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma II. Systemic causes: 2-Renal failure. 3-Hepatic failure . 4-Severe systemic sepsis . 5-Heat stroke and hypothermia . I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma II. Systemic causes: 2-Renal failure. 3-Hepatic failure . 4-Severe systemic sepsis . 5-Heat stroke and hypothermia . 6-Hypertensive encephalopathy . I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma III. Drugs & poisons : Drugs Atropine overdose. Barbiturates overdose. Benzodiazepines overdose. Salicylate poisoning. Narcotics as morphine overdose.. Antihistamines overdose. Theophylline overdose. I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma III. Drugs & Poisons : Poisons Lead poisoning. Kerosene poisoning. Carbon mono-oxide poisoning. Inhalation of carbon tetrachloride, gasoline. Organophosphrus poisoning I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma III. Drugs & poisons : Drugs Poisons Atropine overdose. Barbiturates, benzodiazepines. Salicylate poisoning. Narcotics as morphia. Antihistamines overdose. Theophylline overdose. Lead poisoning. Kerosene poisoning. Carbon mono-oxide poisoning. Inhalation of carbon tetrachloride, gasoline or other cleaning fluids. Organophosphrus poisoning I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Etiologic Classification Of Coma :

Etiologic Classification Of Coma IV. Psycho - neurological problems : Hysteria or functional coma: rare, recognized by exclusion. I. Local CNS causes: 1. Head trauma 2. Vascular: 3. Epilepsy 4. Central nervous system infections: 5. Brain tumors. II. Systemic causes: 1-Metabolic disorders: 2-Renal failure. 3-Hepatic failure. 4-Severe systemic sepsis . 5-Heat stroke and hypothermia. 6-Hypertensive encephalopathy. III. Drugs & Poisons: IV. Psycho - neurological problems:

Persistant Vegetative State:

Persistant Vegetative State Patient is immobile, with decerebrate posturing, but appears to be awake No evidence of awareness of self or environment All responses are reflex in nature No meaningful or voluntary response to stimulation No evidence of language comprehension or expression An intermittent sleep wake pattern

PowerPoint Presentation:

Preserved cranial nerve responses Sufficiently intact hypothalamic (brainstem) autonomic function to allow prolonged survival with nursing and medical care Present for more than one month In patients with PVS for >6mths, there is no prospect for recovery

Akinetic mutism:

Akinetic mutism Patient appears awake No evidence of awareness of self or environment, but may follow a moving object with eyes Communication may sometimes be established by a code based eye blinking May recover and such patients may have excellent recall of events during illness

References:

References Coma and Other States of Altered Awareness in Children. Stavros M. Hadjiloizou and James J. Riviello, Jr. Chapter 25.Clinical paediatric neurology 3 rd edition Huthchinson’s clinical methods 22 nd edition Suchitra ranjit, approach to child with coma Indian paediatrics

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