• Medical emergency. • Incidence TBI – 670/100000 children per year, non-traumatic 30/100000. DEFINITION
• Coma refers to injury and impaired function( arousal and awareness) of the brain due to structural and/or metabolic or systemic etiologies. • Sleep vs COMA • Lethargy refers to drowsiness or decreased wakefullness preserved ability to communicate when appropriately stimulated. • Obtundation refers to a deeper state of unresponsiveness, with loss of ability to respond to vigorous stimuli. • Stupor - arousability only to noxious stimuli. • Encephalitis / Encephalopathy/ Meningitis PHYSIOLOGY • Consciousness is maintained by-bilateral cerebral cortex, thalamus, reticular formation (upper pons , midbrain) Condition awareness wakefulness Physical exam Outcome Brain death absent absent No reflexes or spinal reflexes, No recovery absent respiratory function Coma absent absent No propound movement Death, persistent Variably depressed respiratory vegetative state or effort recovery by 4 weeks. Persistent absent Intact No purposeful movement Depend on etiology vegetative Normal respiratory efforts Minimally Very limited Intact Severe limitation of movement Recovery unknown conscious state Variably depressed respiratory effort
POST IMMUNIZATION ENCEPHALOPATHY- whole cell pertussis, semple rabies vaccine
EXOGENOUS TOXINS AND POISONS Narcotics, neuroleptics, antidepressants, antiepileptic drugs, stimulants Over-the-counter drugs, acetaminophen, mushrooms Industrial toxins (e.g., heavy metals, organic phosphate, cyanide, volatile hydrocarbons) Substance abuse (e.g., alcohol, cocaine, heroin, amphetamine) Cerebral malaria Rickettsial- lyme disease, rocky mountain spotted fever Post seizure states Non-convulsive encephalopathy post migraine COMA WITHOUT FOCAL SIGNS AND WITH MENINGEAL IRRITATION
• Meningitis • Encephalitis • Subarachnoid hemorrhage • 3 year old first born child child was brought by mother with history stating child was apparently normal 2 hours back and with history of fall and GTCS type of convulsions with unconsciousness, with h/o skin infection 5 days back and younger sibling is absolutely fine. HISTORY • Acute deterioration- ingestion of drugs, CVA, trauma, metabolic distrurbances, , intracranial hemorrhage, seizure, or cardiac arrhythmia • Post fever- ADEM (MOG ), neuromyelitis optica spectrum disorder (AQP4), acute necrotizing encephalopathy. • Progressive, gradual- indolent infection, mass lesion, hydrocephalus, or metabolic derangements • Infants- meningitis • Toddler- intoxication • IEM- previous history of still births or deaths (FTT, seizures, vomiting, altered state of consciousness) • Changes in head circumference or headache with positional changes suggest - raised ICP. • Neck stiffness or rigidity suggests meningitis or encephalitis. • Alterations in speech, vision, or motor function may- stroke or seizure. • Incontinence of bowel or bladder function - seizure. • A murmur, gallop, or dysrhythmia may suggest congenital heart disease or endocarditis - stroke or intracranial abscess formation. • A history of medication use, seizures, underlying neurologic disease, structural brain abnormalities, inborn errors of metabolism, diabetes mellitus, autoimmune disease, hepatic or renal failure, history of congenital heart disease or dysrhythmia, or psychiatric disease. • Patients with systemic lupus erythematosus, sickle cell disease, nephrotic syndrome, or coagulation disorders— cerebral infarction resulting from a vascular obstruction. • a 6 year old girl who was apparently normal a month ago then she developed abrupt high grade fever accompanied with cough and cold with no chills or rigors. Patient also had throbbing headache which started suddenly in frontal region a month ago, not associated with vomiting or visual problems, headache was relieved on taking medications. Patient has trouble walking for 20 days. the child used to sway when walking in the first week then started walking with support eventually stopped walking completely. h/o child is unable to speak for 14 days. MRI- MULTIFOCAL DEMYELINATING LESIONS) PHYSICAL EXAMINATION • High grade fever - Infection or ingestion (eg- Anticholinergics or serotonin syndrome). • Hypothermia -infection (infants) or environmental exposure. • Tachycardia - fever, hypovolemia, or arrhythmia • Bradycardia - increased ICP or toxic ingestions • Increased respiratory rate- metabolic acidosis • Odour • High blood pressure – Renal failure, AGN • Petechial haemorrhage with shock –dengue • Neurocutaneous markers • Hemiparesis • Meningeal signs • Hypertension, bradycardia, bulging AF • An 8-month old male baby weighing 6 kg presented with high grade fever for 4 days, one episode of convulsion and altered sensorium. There was history of giving bath in pond water many times in last 1 month. CSF examination showed a sugar of 109.8 mg/dL, protein of 63.9 mg/dL with a cell count of 50 cells/ mm3 (90% lymphocytes and 10% poly-morphs). Gram stain and culture of the CSF did not reveal any bacteria. An wet mount was made to look for fungus which incidentally showed flagellate form of the motile Naegleria fowleri. CONSIDERATIONS
• Complete neurological examination particularly with
1. Level of consciousness 2. Pattern of respiration 3. Size and reactivity of pupils 4. Spontaneous and induced eye movements 5. Motor responses LEVEL OF CONSCIOUSNESS
• AVPU Score 1. A- alert 2. V- responds to voice 3. P- responds to pain 4. U- unresponsive activity infant child Adult Score Eye opening Spontaneous Spontaneous Spontaneous 4 To sound To sound To sound 3 To pain To pain To pain 2 none none none 1 activity infant child adult score motor Moves spontaneously Obeys commands Follows commands 6 Withdraws to touch Localizes pain Localizes pain 5 Withdraws to pain Withdraws to pain Withdraws to pain 4 Decorticate posture to pain Flexion in response to Flexion in response to pain 3 pain Decerebrate Extension in response Extension in response to pain 2 to pain none none None 1 verbal Coos and babbles Age appropriate, oriented 5 smiles, oriented Irritable cries Confused, aware of confused 4 environment Cries in response to pain Irritable, inconsistently Inappropriate words 3 consolable Moans in reponse to pain Inconsolable, unaware Inappropriate sounds 2 of environment, agitated none none none 1 RESPIRATORY PATTERN PUPILLARY SIZE AND REACTIVITY
• Pupillary light reflex is the single most important physical sign differentiating metabolic from structural coma. • Parasympathetic pathway • Sympathetic pathway SPONTANEOUS AND INDUCED EYE MOVEMENTS
1. Oculocephalic Or doll s eye response
2. Oculovestibular or calorie test
Condition Response Awake with intact brainstem Nystagmus with slow component towards irrigated ear and fast component towards midline Unconscious with intact brainstem Eye move towards stimulus and remain tonically deviated >1 minute Unconscious with brain stem dysfunction No response. I.E eye remains midline MOTOR EXAMINATION HERNIATION SYNDROMES INVESTIGATIONS NEURO IMAGING NEURO IMAGING- CT POSSIBLE VIRAL ETIOLOGICAL AGENTS BASED ON CLINICAL PRESENTATION Clinical presentation Virus Focal encephalitis (frontotemporal) HSV Cerebellar ataxia VZV Dementia HIV and Measles Extrapyramidal manifestations JE, Nipha, west nile Retinitis CMV and west nile Rash Measles, rubella, VZV, HFM Diarrhoea Enterovirus RTI features Influenza, H1N1, Adenovirus Parotitis Mumps Hepatitis Coxiella burnetti lymphadenopathy HIV, EBV, CMV ,rubella , west nile HSV ENCEPHALITIS
• When to suspect HSV
1. prolonged convulsions with no obvious precipitating cause. 2. Focal neurological signs , including a focal convulsions 3. A fluctuating conscious level for 6 hours or more 4. Contact with herpetic lesions JAPANESE ENCEPHALITIS
• Definition of suspected case-
• Acute onset of fever, not more than 5-7 days • Change mental status with/without 1. New onset of seizures (excluding febrile seizures) 2. other early clinical findings – Presence of lgM antibody in serum and/ or irritability, abnormal behaviour or CSF to a specific virus including JE/Entero somnolence greater than that seen with Virus usual febrile illness. Antigen detection by immunofluroscence Nucleic acid detection by PCR MANAGEMENT • stabilization of airway • breathing with adequate oxygenation and ventilation • circulation with establishment of vascular or intraosseous access, fluid resuscitation and correction of hypotension, and restoration of end-organ perfusion • avoidance and treatment of hypoglycemia • cervical spine precautions • treatment of intracranial hypertension • treatment of seizures • correction of electrolyte and acid-base abnormalities • avoidance of hyperthermia to prevent unnecessary increases in metabolic demand RAISED ICP
• Skull – Brain parenchyma, blood, csf
• Normal ICP – newborn 6mm Hg , adults- 10-15 mm Hg (1 cm H2O = 1.3 mm Hg) • CPP (cerebral perfusion pressure)= MAP- ICP • Critical CPP- 50 mm Hg (70-110) • PHYSIOLOGICAL VARIABLES AFFECTICTING ICP- paCO2 1mm Hg raise causes 2-6 %increase in CBF paO2 (should not be less than 60mm Hg), temperature, pain • Causes – Increased brain mass, increased CSF volume, increased intracranial blood volume • When to suspect ?? • Neuro imaging CT- obliterated sulci and gyri, poor grey – white differentiation compressed lateral ventricles loss of basal cisterns • Initial stabilization and basic level treatment Stabilize vitals, early and controlled intubation and ventilation, pco2 35-40mm hg, Head end elevation 30 degree, mannitol/ 3%NS, sedation , euvoloemia, euthermia, euglycemia ESCALATED ICP TREATMENT Pco2 30-35 mmHg , thiopentone infusion/midazolam, maintain high normal MAP with pressors, hypothermia 32-34 C for 24 hours, consider surgical options. BRAIN DEATH THANK YOU
