DIAH MUSTIKA HW SpS-KIC

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“As a medical emergency, coma presents a challenge to providers because optimal care requires timely

intervention; however, information is frequently limited during the initial evaluation.”

(Pearson-Shaver and Mehta, Pediatric Critical Care Medicine Textbook, 2007, p. 855)

Mental StatusConsciousness is a condition in which

an individual is fully responsive to stimuli and demonstrates awareness of the environmentAn alteration in mental status is the

hallmark sign of central nervous system (CNS) injury or illness

Mental Status EMT’s evaluate mental status in two ways:

Responsiveness- how does a patient respond to external stimuli

Orientation- checks the patient’s memory and thinking ability

Mental Status Responsiveness is assessed using the AVPU

mnemonic. Alert- patient’s eyes are open spontaneously without

stimuli. Verbal- patient’s eyes open when spoken to. Painful- patient responds to a painful stimuli in some

way (i.e. cries, withdraws, etc). Unresponsive- patient does not respond spontaneously

to any stimuli.

Mental Status Orientation is how the patient responds verbally. This

evaluates the patient’s ability to think and test their memory. The 4 common questions used to evaluate this are: Person- their name Place- where are they Time- year, month, and approximate date Events- what happened

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)

Neural processes that allow for patient to: Perceive Comprehend Act on the internal and external environment

Two neurophysiologic functions: Arousal Awareness

Alert: Fully conscious

Lethargic: appear somnolent, but may be able to maintain arousal spontaneously or with repeated light stimulation

Obtunded: requires touch or voice to maintain arousal

Stuporous: unresponsiveness from which the individual can be aroused only by vigorous and repeated stimulus

Comatose: state of unarousable unresponsiveness in which individual lies with eyes closed, lacking awareness of selfand environment

Levels of Arousal:

Motor Motor ResponseResponse ExampleExample ScoreScoreCommandsCommands Follows simple commandsFollows simple commands 66Localizes Localizes PainPain

Pulls examiner's hand away Pulls examiner's hand away when pinchedwhen pinched 55

Withdraws Withdraws from Painfrom Pain

Pulls a part of body away when Pulls a part of body away when pinchedpinched 44

Abnormal Abnormal FlexionFlexion

Flexes body inappropriately to Flexes body inappropriately to painpain 33

Abnormal Abnormal ExtensionExtension

Body becomes rigid in an Body becomes rigid in an extended position when extended position when examiner pinches himexaminer pinches him 22

No ResponseNo Response Has no motor response to pinchHas no motor response to pinch 11

EyeEye--OpeningOpening ..SpontaneousSpontaneous Opens eyes on ownOpens eyes on own 44

To VoiceTo VoiceOpens eyes when asked to Opens eyes when asked to in a loud voicein a loud voice 33

To PainTo Pain Opens eyes when pinchedOpens eyes when pinched 22No ResponseNo Response Does not open eyesDoes not open eyes 11

Verbal Response Verbal Response (Talking)(Talking) ..

OrientatedOrientated

Carries on a conversation Carries on a conversation correctly and tells examiner correctly and tells examiner where he is, who he is, and where he is, who he is, and the month and yearthe month and year 55

Confused Confused ConversationConversation

Seems confused or Seems confused or disorienteddisoriented 44

Inappropriate WordsInappropriate Words

Talks so examiner can Talks so examiner can understand him but makes understand him but makes no senseno sense 33

SoundsSoundsMakes sounds that Makes sounds that examiner cannot understandexaminer cannot understand 22

No ResponseNo Response Makes no noiseMakes no noise 11

Coma Scales for ChildrenActivity Infants Children ScoreEye Opening Spontaneous Spontaneous 4

To speech To verbal stimuli 3

To pain To pain 2

None None 1

Verbal Coos, babbles Oriented 5

Irritable, cries Confused 4

Cries to pain Inappropriate words 3

Moans to pain Nonspecific words 2

None None 1

Motor Normal movements Follows commands 6

Withdraws to touch Localizes to pain 5

Withdraws to pain Withdraws to pain 4

Abnormal flexion Flexion to pain 3

Abnormal extension Extension to pain 2

None None 1

Pathophysiology: Consciousness depends on proper function of both

cerebral hemispheres and the reticular activating system (RAS)

Normal function requires Adequate substrate (primarily glucose) Cofactors Waste removal Adequate blood flow needed for delivery/removal

Increased neuronal excitability Restless/Confusion Tremor/Delirium

Decreased neuronal excitability Lethargic Obtunded

Stupor Coma

Roads to coma…

Stabilization:

Stabilization: Airway

Assess for patency Assess for ability to protect

Breathing Assess ventilation Assess breathing pattern

Circulation Assess measures of cardiac output

Stabilization: D = “Da brain” Decision point

Concern for No concern for increased ICP increased ICP

Stabilization: Increased ICP Must act immediately

No increased ICP Time to consider your workup

Evaluation: History Physical Exam Laboratory and Imaging Studies

Evaluation—History: Rapid initial history:

Recent history prior to mental status changes Past medical history (seizures) Family history (specifically seizures/neurologic disorders) Trauma ? Febrile ? / Other signs or symptoms of infection Diet Exposure to drugs/toxins

Follow-up with more complete history:

Evaluation—Physical Exam: Systemic

Vital Signs Signs of trauma Signs of infection Signs of bleeding Signs of other systemic illnesses

Evaluation—Physical Exam: Rapid Neurologic Exam:

Pupils Respiratory pattern Stimuli needed to elicit response Character of the response

Neurologic Exam—Pupils:

Respiratory patterns:

Cheyne-Stokes

Central Hyperventilation

Apneustic

Cluster breathing/Gasping

Agonal breathing

Hemispheric

Midbrain

Mid/Lower Pons

Low Pons/Upper Medulla

Medulla

Location Pattern

Posturing:

Decorticate

lesion above midbrain

Decerebrate

lesion below midbrain

Etiologies—Differential by Age: InfantInfant

Infection Inborn Error of

Metabolism Metabolic Abuse Trauma

ChildChild Ingestion Infection Intussusception Seizure Abuse Trauma

AdolescentAdolescent Ingestion Intentional Trauma Drug/Alcohol

overdose

(Pearson-Shaver & Mehta in Pediatric Critical Care Medicine Textbook, 2007, p. 857)

Summary: Coma is altered consciousness with loss of arousal and awareness Stabilization

ABC’s Decide about increased ICP

Evaluation Rapid history and physical Rapid Neuro Exam—Pupils, Resp Pattern, Stimuli and Response

Etiologies Toxic/Metabolic Infectious Structural/Intrinsic Paroxsymal

QUESTIONS?