Coma

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ILOs
▪ Definition
▪ Pathophysiology
▪ Etiology
▪ Evaluation
▪ Treatment

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Definition

Coma
Coma is an acute life-threatening neurological emergency,
requires prompt intervention for preservation of life & brain function,
It is a state of unconsciousness;
the patient is completely “unaware” of self and surroundings, and
“Unarousable unresponsiveness” that he cannot be aroused or responds
to ordinary stimuli (verbal, sensory or physical).

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Pathophysiology
The normal state of consciousness comprises the
state of awareness, wakefulness, responsive to
stimulation, and ability to recall past events.

The conscious state depends on intact cerebral

hemisphere interacting with the ascending
reticular activating system (RAS) in the brain stem,
hypothalamus and thalamus.

Lesions diffusely affecting the cerebral hemisphere

or directly affecting the RAS can cause impairment
of conscious level.

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Etiology

Coma with focal signs

•Intracranial hemorrhage
•Stroke: arterial ischemic or sinovenous thrombosis
•Tumors
•Focal infections-brain abscess
•Post seizure state: Todd’s paralysis

Coma without focal signs and with meningeal irritation

•Meningitis
•Encephalitis
•Subarachnoid hemorrhage

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Coma without focal signs and without meningeal irritation
•Hypoxia-Ischemia: Cardiac or respiratory failure, Cardiac arrest, Shock,
Near drowning, CO poisoning
•Metabolic disorders:
Hypoglycemia
Acidosis (e.g. Organic acidemias, diabetic keto-acidosis)
Hyperammonemia (e.g. hepatic encephalopathy, urea cycle disorders)
Uremia
Fluid and Electrolyte disturbances (dehydration, Na+)
•Systemic Infections: e.g. Sepsis, Shigella encephalopathy
•Inflammatory disorders e.g. SLE
•Alcohol (accidental ingestion)
•Drugs and toxins e.g. opiate, salicylate, barbiturate, antihistamine
•Hypertensive encephalopathy
•Post seizure states
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Evaluation

History
A careful history should be taken with special emphasis on the events prior
to the onset of coma. Presence of fever, headache, vomiting, irritability,
seizures, rash and the duration of symptoms must be enquired. A history of
inborn errors of metabolism. History of trauma, drug/toxin exposure,
seizures, past medical illnesses, and family history must be elicited
Examination
General examination
The most important:
1. Vital signs
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2. Head Examination
▪ Skin & Mucous membrane
Examination of skin and mucous membranes may reveal helpful etiological
clues. The head and scalp should be examined for evidence of head
trauma. Cherry red discoloration with CO poisoning. Cyanosis suggests
poor oxygenation, pallor suggests anemia or shock, and jaundice is
indicative of liver dysfunction.
▪ Basilar skull fracture
- CSF rhinorrhea or otorrhea, or
- Bloody discharge from middle ear, or
- Battle sign (bruising over the mastoid)
▪ Anterior Fontanelle
Bulging fontanelles in encephalitis, meningitis, hydrocephalus, other causes
of increased intracranial pressure. Depressed fontanelle in dehydration.
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 ▪ Eye Examination
Pupils: - Pin-point (narcotics (morphine), barbiturate toxicity,
organophosphorus poisoning, pontine hemorrhage)
- Dilated unresponsive (postictal state, cocaine, alcohol)
- Unilateral dilated unresponsive (herniation of the uncus
of ipsilateral temporal bone)
Extraocular muscles: They can be tested by doll’s eye maneuver
▪ Odor
Fruity (DKA) or putrid (hepatic coma).
3. Neck examination
Nuchal rigidity: Meningitis, encephalitis, subarachnoid
hemorrhage, herniation of cerebellar tonsils.

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Systemic Examination
▪ Chest examination is helpful to detect underlying pneumonia or empyema.
▪ Cardiovascular examination may suggest congenital or rheumatic heart
disease, both of which predispose the patient to endocarditis and
subsequent intracranial abscess dissemination.
▪ Abdominal examination is important to detect hepatosplenomegaly which
maybe present in many infective conditions and liver disease.
▪ Neurologic examination
Immediate neurologic exam include:
➢ Level of consciousness The neurological
examination gives
➢ posturing important information
about the potential
➢ Signs of ICP & Herniation syndrome causes and localization
of brain dysfunction.
➢ Signs of lateralization
➢ Meningeal irritation signs
➢ Brainstem function
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 ➢Level of consciousness
❑ AVPU score

❑ Glasgow Coma Scale (GCS)

Total score 15 points. Patients with a score of 8 or less
require management include stabilization of the airway
and breathing with endotracheal intubation and
mechanical ventilation. A score 3/15 means brain death.
N.B Murray score is done for intubated children.
Total score is 10 points. A score 2/10 means brain death
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 ➢Posturing
Decorticate
• Arms are flexed, fists clenched and legs extended
• Indicate damage to cerebral hemispheres or internal capsule
• Generally a less severe sign compared to cerebrate
posturing
• May still allow for some level of recovery

Decerebrate
• Indicate severe brain stem damage
• Extension and pronation of arms and extended legs.
• More ominous sign of neurological injury
• Often associated with poor prognosis

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➢ Signs of ICP & Herniation syndrome
Clinical presentation of raised ICP

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1) Subfalcial (cingulate) herniation
2) Uncal herniation Uncus= anteromedial portion of temporal lobe which herniates
medially into tentorial notch causing compression on 3rd nerve the brain stem as it
progresses 1. ipsilateral cranial nerve III palsy, 2. contralateral hemiplegia, 3. coma
3) Downward Central Transtentorial herniation
4) External herniation (Transcalvarial)
5) Downward cerebellar (Tonsillar) herniation Cushing reflex
6) Upward cerebellar herniation
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 ➢Signs of lateralization
• Unequal pupils, impaired light reflex
• Deviation of the eyes to one side
• Facial asymmetry
• Turning of the head to one side
• Unilateral hypo-hypertonia
• Asymmetric deep reflexes
• Unilateral extensor plantar response (Babinski)
• Unilateral focal or Jacksonian fits

➢Meningeal irritation signs

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 ➢Brainstem function
The presence of pupillary light reflex, oculocephalic (doll’s eye),
oculovestibular, corneal, cough and gag reflexes are indicative of intact
brainstem function.
• Pupillary light reflex: (CN 2,3; midbrain)

• Oculocephalic (doll’s eye) reflex: (CN 3,6,8; midbrain, pons)

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• Oculovestibular (caloric reflex): (CN 3,4,6,8; pons, midbrain)

• Corneal reflex: (CN 3,5,7; pons)

• Gag and cough reflex: (CN 9,10; medulla)

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 Investigations Fundus
Gastric content
The stomach is examination
Blood emptied and To detect
Urine papilledema and
• CBC  Sugar
should be analyzed
retinal
• ABG  Ketone bodies
for drugs
hemorrhage
• blood glucose  Urine volume Imaging
• Na, K, Ca, Ph, Mg
• Skull X ray (fractures)
• RFTs
Lumber Puncture (LP) • CT brain (if coma with
• LFTs lateralization)
• PT,PTT Contraindications of LP:
• MRI brain
• Signs of impending herniation
• Ammonium level
• Prolonged or focal seizures • EEG
• Toxin screen
• Focal neurological signs • ICP monitor
• GCS<13
• Coagulation disorders

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Treatment
➢ ABC
• Airway: open the airway
• Breathing:O2/ventilation
• Circulation: diagnose and treat shock
➢ Monitoring
• Conscious level
• Vital signs
• Blood sugar, acid-base (ABG), fluid & electrolyte
• ICP to assess cerebral perfusion
CPP= MAP ─ ICP
That CPP; cerebral perfusion pressure.
MAP; mean arterial pressure.
ICP; Intracranial pressure.

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 ➢ Position
The child should lie on one side or semi-prone to avoid aspiration

➢ IVF
• DKA … DKA treatment protocol??
• Other causes … fluid volume should be adjusted for fear of overhydration
due to SIADH as a result of hypothalamic dysfunction ( water
intoxication cerebral edema), correction of fluid, acid-base, and
electrolytes.
• Hypoglycemia … 2ml/kg of 10% dextrose I.V
➢Feeding
Nasogastric tube feeding is always used

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 ➢ Treatment of the cause e.g.
• Meningitis …… Antibiotics (ceftriaxone)
Consider acyclovir
Consider dexamethasone for [Link]
Consider TTT of raised ICP
• Poisoning e.g. Opiate poisoning…
Key features (Hx of ingestion, pin point pupil)
TTT ... Naloxone (10 mcg/kg IV/IO)

➢ Measures to increase the cerebral perfusion

as CPP= MAP ─ ICP , When to say intracranial hypertension??
so measures to increase systemic BP If ICP > 20 mmHg for > 5 minutes.
▪ Mild: 20-29 mmHg.
& measures to lower raised ICP ▪ Moderate: 30-40 mmHg.
N.B Don’t cannulate head and neck ▪ Severe: > 4o mmHg.
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• Measures to increase systemic BP
(Maintain high normal mean ABP)
- May consider inotropes
• Measures to lower raised ICP
- Position: Head elevation 30O & centralized
- Controlled ventilation (PaCO2 targets to 35− 40 mmHg)
- Osmolar agents as mannitol or hypertonic saline
- Drainage of CSF through the ventricular catheter

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