dr. ta ogunlesi (fwacp)1 evaluation of the unconscious child

DR. TA OGUNLESI (FWACP) 1

EVALUATION OF THE UNCONSCIOUS

CHILD

EVALUATION OF THE UNCONSCIOUS

CHILD

DR. TA OGUNLESI (FWACP) 2

COMA• COMA is a state of complete:

absence of awareness of self

absence of purposeful responsiveness to the environment

absence of cognitive and mental functions.

DR. TA OGUNLESI (FWACP) 3

COMA• Consciousness depends on the

interaction between the cerebral hemispheres and the Reticular Activating System (RAS), the arousal mechanism of the upper brain stem.

• Altered sensorium results from either widespread cerebral disorder or destruction of the upper brainstem.

DR. TA OGUNLESI (FWACP) 4

GRADES OF ALTERED SENSORIUM

Drowsiness-patient is easily arousable.Delirium-patient has extreme motor

agitation and severe disorientation with delusions and hallucination.

Stupor-patient arousable only on vigorous external stimulation.

Semi-consciousness-patient responds to vigorous stimulation with reflex limb movement but without mental response.

Coma-patient is completely unarousable.

DR. TA OGUNLESI (FWACP) 5

AETIOLOGY OF COMA IN CHILDREN

• Metabolic –more common in children (>50% of cases); gradual onset with slow progression and diffuse pattern of signs. The precise cause of coma is unclear but it is often due to cerebral oedema.

• Structural- less common; sudden onset with rapid progression and focal distribution of signs.

Supratentorial Infratentorial TranstentorialThe cause of coma is usually due to compression

or direct destruction of the cerebrum and herniation of the brainstem.

DR. TA OGUNLESI (FWACP) 6

ACUTE BRAIN INJURY• Alteration in sensorium usually

results from acute brain injury which may be:

Traumatic (intracranial bleeding)Infectious (meningitis/

encephalitis)Metabolic (glucose, electrolyte

derangements)Hypoxic (status epilepticus,

cardiac arrest)

DR. TA OGUNLESI (FWACP) 7

ACUTE BRAIN INJURY• These injuries secondarily cause

cerebral oedema via alteration in the cerebral blood flow and perfusion.

• ↑Cerebral perfusion results in CEREBRAL OEDEMA formation which further worsens the elevated intracranial pressure.

• Major risk of raised intracranial pressure is herniation of the brainstem into the foramen magnum (a.k.a coning)

DR. TA OGUNLESI (FWACP) 8

WHEN TO SUSPECT CEREBRAL OEDEMA

• Gradual decline in consciousness• Unequal or fixed pupillary dilatation• Cushing’s Triad• Conjugate or disconjugate eye

deviation• Development of decorticate or

decerebrate rigidityNote that the classical features of

headache, effortless vomiting and blurred vision are only found in chronically elevated intracranial pressure.

DR. TA OGUNLESI (FWACP) 9

AETIOLOGY• StructuralCerebral contusions or lacerations with

hematomas,Cerebral abscessesSubdural effusions and empyemaCerebrovascular diseases (AV

malformations, aneurysms) Cerebral tumoursCerebral parasitic cysts (Cysticercosis;

hydatidosis)

DR. TA OGUNLESI (FWACP) 10

AETIOLOGY• Metabolic & DiffuseHypoglycaemiaHyperbilirubinaemiaHypothermiaSevere anaemiaInfections (Cerebral

malaria, meningitis, encephalitis, cortical thrombophlebitis)

Hypoxic-ischaemic encephalopathy

EpilepsyDKAAlcohol intoxication

Hypertensive encephalopathy

Hepatic encephalopathyUraemic encephalopathyAddison diseaseThyroid crisisReye syndromeAmino-aciduriaOrganic aciduria

DR. TA OGUNLESI (FWACP) 11

ASSESSMENT OF SENSORIUM

• GLASGOW COMA SCALE/ SCORE

• Applicable for children aged 4- 15 years

• Maximum score = 15

• Minimum score = 3

• Coma = score <8

Best Eye Opening

Best Verbal Response

Best Motor Response

Spontaneous -4

Fully alert-5 Obeys command-6

To speech-3 Confused conversation-4

Localizes-5

To pain-2 Inappropriate words-3

Withdraws-4

No response-1

Incomprehensible sounds-2

Flexor posturing-3

No response-1

Extensor posturing-2

No response-1

DR. TA OGUNLESI (FWACP) 12

ASSESSMENT OF SENSORIUM

• MODIFIED GLASGOW COMA SCALE/ SCORE

• Applicable for children aged <4 years

• Maximum score = 15

• Minimum score = 3

• Coma = score <8

Best Eye Opening

Best Verbal Response

Best Motor Response

Spontaneous -4

Smiles & interacts-5

Spontaneous or obeys command-6

To speech-3 Consolable cry-4

Localizes-5

To pain-2 Persistently irritable-3

Withdraws-4

No response-1

Restless & Inconsolable cry-2

Flexor posturing-3

No response-1

Extensor posturing-2

No response-1

DR. TA OGUNLESI (FWACP) 13

ASSESSMENT OF SENSORIUM

• BLANTYRE COMA SCALE/ SCORE

• Applicable for children who have not learnt to speak.

• Maximum score = 5

• Minimum score = 0

• Coma = score <2

Best Eye Opening

Best Verbal Response

Best Motor Response

Directed (eg towards mother’s face) -1

Appropriate cry-2

Localises well-2

Not directed-0

Moan or inappropriate cry -1

Withdraws from pain-1

None-0 Non-specific or total absence-0

DR. TA OGUNLESI (FWACP) 14

ASSESSMENT OF AN UNCONSCIOUS CHILD

OBJECTIVE-To minimise further brain injury• Ensure adequate resuscitationa. Clear the airwaysb. Secure the airways by positioning in the left

lateral. Insertion of an oro-pharyngeal airway may be necessary.

c. Maintain circulation with the appropriate Intravenous Fluid (Normal Saline if shocked; Dopamine or dobutamine infusion may be necessary if in shock; dextrose-containing IVF in other cases).

DR. TA OGUNLESI (FWACP) 15

ASSESSMENT OF AN UNCONSCIOUS CHILD

a. Check RBS even if with Dextrostix & correct hypoglycaemia if present.

2. Brief history focused on:b. Mode of onset of impaired

sensoriumc. Course and duration of illnessd. Drug use history

DR. TA OGUNLESI (FWACP) 16

ASSESSMENT OF AN UNCONSCIOUS CHILD

3. Thorough physical examination focused on:

a. Assessment of sensorium using the Glasgow, Modified Glasgow or Blantyre scales.

b. Check for tense anterior fontanelle in infants; evidences of head injury: skull fracture or scalp lacerations.

c. Check the pupils for size, equality and reaction to light.

DR. TA OGUNLESI (FWACP) 17

ASSESSMENT OF AN UNCONSCIOUS CHILD

d. Check for meningeal irritation with Kernig or Brudzinski signs.

e. Examine the fundus for papilloedema (raised intra-cranial pressure) or choroidal tubercules (miliary TB).

f. Observe conjugate eye movements. Note the resting position of the eyes first and then briskly turn the head to either side to elicit the DOLL’S EYE MOVEMENT (OCULOCEPHALIC REFLEX).

DR. TA OGUNLESI (FWACP) 18

ASSESSMENT OF AN UNCONSCIOUS CHILD

Deviation of the eyes to the contralateral side suggests cortical or brain stem depression. This manoeuvre brings the eyes beyond the midline in cortical diseases but not in brainstem diseases.

Downward deviation of the eyes (setting sun appearance) suggest mid-brain compression

DR. TA OGUNLESI (FWACP) 19

ASSESSMENT OF AN UNCONSCIOUS CHILD

h. Assess the pulses and BP. Bradycardia and hypertension and apnoea (CUSHING’S TRIAD) suggest raised intra-cranial pressure but the triad is NOT always present.

DR. TA OGUNLESI (FWACP) 20

ASSESSMENT OF AN UNCONSCIOUS CHILD

i. Examine the cranial nerves (particularly squint for 3rd, 4th and 6th; corneal reflex for 5th; facial deviation for 7th)

j. Examine the nose and ears for CSF drainage in cases of skull basal fracture.

k. Examine the mouth: breath of alcohol, ketones, native herbs. Tongue laceration may indicate recent seizure.

DR. TA OGUNLESI (FWACP) 21

ASSESSMENT OF AN UNCONSCIOUS CHILD

i. Observe the posture (decorticate or decerebrate)

j. Examine the motor (bulk, tone, reflexes, power) and sensory functions (pain and superficial reflexes in particular).

k. Examine the skin and mucous membranes for palor, jaundice and uraemic frosts.

DR. TA OGUNLESI (FWACP) 22

RELEVANT LABORATORY

INVESTIGATIONS• CT Scan/ MRI• Cerebral angiography/ Ventriculography• Electroencephalography (EEG)• Skull X-Ray • CBC including ESR• RBS• Serum Electrolytes & Urea• LFT• Lumbar Tap if meningitis is suspected and

evidences of raised intracranial pressure are absent.

DR. TA OGUNLESI (FWACP) 23

CONTRAINDICATIONS TO LUMBAR TAP IN A

COMATOSE PATIENT• Cardiopulmonary instability• Advanced brainstem dysfunction

(eg. decerebrate posturing)• Gross skin sepsis over the spine• Evidence of Space-Occupying

Lesion

DR. TA OGUNLESI (FWACP) 24

MANAGEMENT1. Treatment of specific

aetiology2. Supportive management• Left-lateral positioning to

prevent aspiration• Frequent oro-pharyngeal

suctioning to prevent aspiration

DR. TA OGUNLESI (FWACP) 25

• Endotracheal intubation if apnoea occurs

• Maintenance of caloric and fluid intake via IVF, hyperalimentation or nasogastric intubation

• Urethral catheterisation• Treatment of pressure areas to

prevent decubitus ulcers

DR. TA OGUNLESI (FWACP) 26

MANAGEMENT3. Treatment of cerebral oedema• Elevation of the head to 15 to 300

optimises the cerebral perfusion pressure

• Control of fever prevents ↑ cerebral blood flow, cerebral perfusion and oedema. Antipyretics and muscular paralysis to prevent shivering may be helpful.

DR. TA OGUNLESI (FWACP) 27

• Assisted Ventilation: To achieve hypocapnoea which causes cerebral vasoconstriction and reduces cerebral swelling.

• Deliberate under-hydration (2/3 to ¾ of normal fluid requirement) has not been found to improve outcome because it further reduces resultant CPP.

DR. TA OGUNLESI (FWACP) 28

MANAGEMENTControl of seizures with anticonvulsants

(seizures increases the metabolism of brain tissue and ↑ the risk of oedema).

Mannitol is used when herniation is imminent. Given as 0.5-1g/kg by rapid IV infusion over 20 minutes. Causes osmotic diuresis. May be repeated in 4 hours.

Corticosteroids (Dexamethazone 0.2mg/kg/day iv or im) are useful only in vasogenic cerebral oedema (found in cases of CNS infections, abscesses and tumours).